BI Waiver Interest Form

Brain Injury Waiver Interest Form

Fill out the form carefully
Applicant Information*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Race

WhiteBlack or African AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific Islander
Ethnicity

Hispanic or LatinoNon Hispanic or LatinoNot specified
Cause of Brain Injury*
* IF OTHER, PLEASE SPECIFY
Date of Brain Injury*

MonthDayYear
Estimated Monthly Income
Estimated total assets
What sources of income does the individual have?

SSISSDIIncome from WorkWorkers CompensationUnknownOther
Does the individual have Medical Assistance / Medicaid?

YesNo
Current facility / residence*

Facility Name

Street Address

CityState / Province

Postal / Zip Code
Date of admission to the facility (if applicable)

MonthDayYear
Contact at the Facility/placement

First NameLast Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Why is this individual being referred?
Upload Clinical information here

Cancelof
Person Making the Referral*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Point of contact if a waiver slot becomes available (family, facility contact, etc.)*

First NameLast Name
Email*
example@example.com
Relationship to consumer*
Ex: Partner, mother, POA, guardian, social worker, etc.
Phone Number*
Format: (000) 000-0000.
Should be Empty:

Brain Injury Waiver Interest Form