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DHS-DDS-TBI-1:Traumatic Brain Injury Fund Application (v1)

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TRAUMATIC BRAIN INJURY FUND APPLICATION

INSTRUCTIONS: Complete the application below and sign it to be considered for eligibility to the Traumatic Brain Injury Fund. All required fields must be completed before the application can be submitted. Additionally, once you have submitted your application, your healthcare provider will automatically be emailed the Medical Form to complete and sign. Once your completed application is received, it will be reviewed and you will be notified of your eligibility. You may contact the TBI Fund at 1-888-285-3036, prompt #1 for questions or assistance with completing the application. Please note: Power of Attorney and legal guardians should include paperwork to verify such status at the time of the application.

Items in * are required fields.

Applicant Information

First Name *

Middle Initial

Form field Middle Initial has Invalid alphanumeric value.

Last Name *

Address *

Apt/Unit/Suite/POBox Number

Phone *

Phone form field Phone must be in the format: (000) 000-0000

Email (This email will be used for acknowledgment and notifications) *

Email form field Email (This email will be used for acknowledgment and notifications) is not in correct form

Date of Birth *

Date form field Date of Birth must be in the format: MM/dd/yyyy

Upload one of the documents from a list below *

Upload one of the documents from a list below

Driver’s License

State ID

Government Issued Correspondence

Current Utility Bill

Upload your document *

Form field Upload your document has Invalid files.

Preferred Method of Communication

Preferred Method of Communication

Verbal

Written

Verbal with written follow-up

Is someone filling this form out on your behalf?

Is someone filling this form out on your behalf?

Yes

No

Person filling out the form, if different from the Applicant: * Value is not selected

Upload Documentation of Power of Attorney or Legal Guardian *

Form field Upload Documentation of Power of Attorney or Legal Guardian has Invalid files.

Provide explanation for "Other" *

First Name *

Middle Initial

Last Name *

Address *

Apt/Unit/Suite/POBox Number

Phone *

Phone form field Phone must be in the format: (000) 000-0000

Email *

Email form field Email is not in correct form

Applicant Demographic Information

Citizenship Status * Value is not selected

Certificate Type * Value is not selected

Upload US Passport (expired is ok) or Permanent Resident Card *

Form field Upload US Passport (expired is ok) or Permanent Resident Card has Invalid files.

Certificate # *

Marital Status * Value is not selected

Gender Identity * Value is not selected

Race/Ethnicity * Value is not selected

Level of Education * Value is not selected

Do you have dependent children? (A dependent is a qualifying child who relies on you for financial support) * Value is not selected

Employment Status * Value is not selected

What is your living situation? * Value is not selected

Own or Rent? *

Own or Rent?

Own

Rent

Medical Information

Year most recent TBI occurred (yyyy) * Value is not selected

Date TBI occurred (mm/dd)

Date form field Date TBI occurred (mm/dd) must be in the format: MM/dd

Cause of TBI *

Treatment received for TBI *

Financial Information

Annual Income (For applicants 18 years or younger, income of parents or guardian. For married applicants, total combined marital income) $ *

Currency Form field Annual Income (For applicants 18 years or younger, income of parents or guardian. For married applicants, total combined marital income) $ requires format 1,000.00

Wages ($), If not received, enter $0 *

Currency Form field Wages ($), If not received, enter $0 requires format 1,000.00

How often? Value is not selected

Social Security ($), If not relevant to you, enter $0 *

Currency Form field Social Security ($), If not relevant to you, enter $0 requires format 1,000.00

How often? Value is not selected

Alimony received ($), If not relevant to you, enter $0 *

Currency Form field Alimony received ($), If not relevant to you, enter $0 requires format 1,000.00

How often? Value is not selected

Worker’s Compensation/ Disability ($), If not relevant to you, enter $0 *

Currency Form field Worker’s Compensation/ Disability ($), If not relevant to you, enter $0 requires format 1,000.00

How often? Value is not selected

Other income ($), If not relevant to you, enter $0 *

Currency Form field Other income ($), If not relevant to you, enter $0 requires format 1,000.00

How often? Value is not selected

You have indicated $0 income. How do you pay your bills? *

Have you received a settlement or civil judgment made in connection to your TBI? *

Have you received a settlement or civil judgment made in connection to your TBI?

Yes

No

Do not know

Type of Settlement * Value is not selected

Docket Number *

Amount of settlement $ *

Currency Form field Amount of settlement $ requires format 1,000.00

Attorney Name *

Attorney Email *

Email form field Attorney Email is not in correct form

Attorney Phone *

Phone form field Attorney Phone must be in the format: (000) 000-0000

Attorney Address *

Are there any pending claims such as, lawsuits, divorce settlements, inheritance, accident claims, medical malpractice, or other claims?  *

Are there any pending claims such as, lawsuits, divorce settlements, inheritance, accident claims, medical malpractice, or other claims? 

Yes

No

Do not know

If yes, please provide details of the claims, including but not limited to, the date monies were received and the type of claim. *

Do you have liquid assets $100,000 or more?

“Liquid assets” are assets that are convertible to cash within 30 days. Liquid assets for the applicant or his or her immediate family include checking and savings accounts, stocks, bonds, treasury notes, and similar instruments. The home where the Applicant lives, vehicles, and personal property are not considered liquid assets. For applicants 18 years or younger, liquid assets of the parent(s)/guardian(s) will be considered. Individual and jointly held assets of married couples will be considered. "Immediate family" is defined as: Biological or adoptive parent(s) or other persons who have been legally determined to be financially responsible for an applicant/beneficiary who is under the age of 18 or Persons who have been legally determined to be financially responsible for an applicant/beneficiary who is over the age of 18, including a legally recognized partner. *

“Liquid assets” are assets that are convertible to cash within 30 days. Liquid assets for the applicant or his or her immediate family include checking and savings accounts, stocks, bonds, treasury notes, and similar instruments. The home where the Applicant lives, vehicles, and personal property are not considered liquid assets. For applicants 18 years or younger, liquid assets of the parent(s)/guardian(s) will be considered. Individual and jointly held assets of married couples will be considered. "Immediate family" is defined as: Biological or adoptive parent(s) or other persons who have been legally determined to be financially responsible for an applicant/beneficiary who is under the age of 18 or Persons who have been legally determined to be financially responsible for an applicant/beneficiary who is over the age of 18, including a legally recognized partner.

Yes

No

Savings Amount ($) *

Currency Form field Savings Amount ($) requires format 1,000.00

Please upload prior bank statements (1) *

Form field Please upload prior bank statements (1) has Invalid files.

Please upload prior bank statements (2) *

Form field Please upload prior bank statements (2) has Invalid files.

Please upload prior bank statements (3) *

Form field Please upload prior bank statements (3) has Invalid files.

Additional saving account

Additional saving account

Yes

No

Additional Saving amount ($) *

Currency Form field Additional Saving amount ($) requires format 1,000.00

Please upload prior bank statements (1) *

Form field Please upload prior bank statements (1) has Invalid files.

Please upload prior bank statements (2) *

Form field Please upload prior bank statements (2) has Invalid files.

Please upload prior bank statements (3) *

Form field Please upload prior bank statements (3) has Invalid files.

Checking Amount ($) *

Currency Form field Checking Amount ($) requires format 1,000.00

Please upload prior bank statements (1) *

Form field Please upload prior bank statements (1) has Invalid files.

Please upload prior bank statements (2) *

Form field Please upload prior bank statements (2) has Invalid files.

Please upload prior bank statements (3) *

Form field Please upload prior bank statements (3) has Invalid files.

Additional checking account

Additional checking account

Yes

No

Additional Checking Amount ($) *

Currency Form field Additional Checking Amount ($) requires format 1,000.00

Please upload prior bank statements (1) *

Form field Please upload prior bank statements (1) has Invalid files.

Please upload prior bank statements (2) *

Form field Please upload prior bank statements (2) has Invalid files.

Please upload prior bank statements (3) *

Form field Please upload prior bank statements (3) has Invalid files.

Stocks/Bonds ($)

Currency Form field Stocks/Bonds ($) requires format 1,000.00

Please upload most recent Stock/Bonds Quarterly statement(s) *

Form field Please upload most recent Stock/Bonds Quarterly statement(s) has Invalid files.

Other Assets($) (i.e. Trust Fund)

Currency Form field Other Assets($) (i.e. Trust Fund) requires format 1,000.00

Please upload most recent Other Assets Quarterly statement(s) *

Form field Please upload most recent Other Assets Quarterly statement(s) has Invalid files.

Do you receive Direct Express? *

Do you receive Direct Express?

Yes

No

Please upload prior bank statements (1) *

Form field Please upload prior bank statements (1) has Invalid files.

Please upload prior bank statements (2) *

Form field Please upload prior bank statements (2) has Invalid files.

Please upload prior bank statements (3) *

Form field Please upload prior bank statements (3) has Invalid files.

Do you own or have interest in whole or in part, any properties other than your primary residence (including but not limited to other homes, land, and buildings)? *

Do you own or have interest in whole or in part, any properties other than your primary residence (including but not limited to other homes, land, and buildings)?

Yes

No

Type(s) of Property *

Address of Property

Type(s) of Property

Address of Property

Type(s) of Property

Address of Property

Health Insurance Information

Do you have health insurance? *

Do you have health insurance?

Yes

No

Type of insurance *

Type of insurance

Private

Medicaid Managed Care Organization (MCO)

Medicare

Dental

Vision

Other

Private Policy Name *

Private Policy Number *

Medicare Part A Date Eligible *

Date form field Medicare Part A Date Eligible must be in the format: MM/dd/yyyy

Medicare Part B Date Eligible

Date form field Medicare Part B Date Eligible must be in the format: MM/dd/yyyy

Medicare Part C Date Eligible

Date form field Medicare Part C Date Eligible must be in the format: MM/dd/yyyy

Medicare Part D Date Eligible

Date form field Medicare Part D Date Eligible must be in the format: MM/dd/yyyy

Medicaid Managed Care Organization (MCO) Name

Medicaid Managed Care Organization (MCO) Policy Number *

Dental Policy Name *

Dental Policy Number *

Vision Policy Name *

Vision Policy Number *

Other, please explain *

Services Information

Are you currently enrolled or applying for any of these program(s)?

Are you currently enrolled or applying for any of these program(s)?

Personal Assistance Service Program (PASP)

Division of Developmental Disabilities (DDD) Waiver

Jersey Assistance for Community (JACC)

Managed Long Term Services and Supports (MLTSS)

Veteran Affairs

Worker's Compensation

Pharmaceutical Assistance to the Aged & Disabled (PAAD)/Senior Gold

Other Services

Supplemental Nutrition Assistance Program (SNAP)

Any service or support available to the general public through a governmental program or agency *

*

I understand the information I submit is subject to verification which I will need to provide. I give permission to the Division of Disability Services and its agents/contractors to contact individuals or other sources that may have knowledge about my circumstances necessary to determine this application. I understand that the Department of Human Serivces, including its Divisions, eligibility determining agencies, government contractors, and other appropriate State of New Jersey agencies, may exchange information relating to coverage to assist with this application, enrollment, administration, and billing services. I give permission for the TBI Fund Review Committee to review all information necessary to render decisions regarding my application and request for services. I understand that I must sign the attached release for medical documentation in order for my application to be processed. I give third parties permission to share information about me with authorized State staff to assist with this application, enrollment and administration. I understand that I cannot have more than $100,000 in liquid resources. I understand that I must provide any updates and changes to any information provided on this application including but not limited to, my residence, other health insurance coverage, changes in resources and the filing or outcome of lawsuits. I understand that the TBI Fund has a legal right to be reimbursed for services from any monies received as a result of a settlement, judgement or other payment stemming from the traumatic brain injury. I understand that if I use services and supports without the approval from the TBI Fund/Review Committee, I will have to pay for those services and supports because the TBI Fund will not pay for the service or support provided or obtained prior to the written notification containing the date of the approval.

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508

*

I agree to the release of the medical information below to the Traumatic Brain Injury Fund for the purposes of determining eligibility. I understand that the TBI Fund reserves the right to contact listed physician for clarification of this information, and that medical information is protected under the Health Insurance Portability and Accountability Act (HIPAA).

By signing below, I certify that the information provided is true, correct and complete to the best of my knowledge. I also certify that I have read and understand my responsibilities under this Fund.

Name *

Date *

Date form field Date must be in the format: MM/dd/yyyy

Signature

Signature form field Signature is required

Your Physician Name *

Your Physician Email *

Email form field Your Physician Email is not in correct form

Confirm Your Physician Email *

Email form field Confirm Your Physician Email is not in correct form

For Office Use Only:

Was this information entered in manually by a DDS employee on behalf of the applicant?

Was this information entered in manually by a DDS employee on behalf of the applicant?

Yes

No

If yes, please upload a scanned copy of original filled and signed form received from an Originator. (Must include, signed "HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508") *

Form field If yes, please upload a scanned copy of original filled and signed form received from an Originator. (Must include, signed "HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508") has Invalid files.

Note: All attachments combined size should be less than 30MB.
If you are facing any issues submitting this application online, please contact the NJ TBI Fund at DHSCO.DDS-TBIFund@dhs.nj.gov or call 1-888-285-3036.

Email Address: