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Respite Assistance Application

First name*

Last name*

Medicaid # (if applicable)

Birthday*

Month

Day

Year

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Name of person assisting with application (if applicable):

Description of brain injury: *

Description of physical and cognitive needs: *

Does the survivor require 24/7 supervision?*

Yes

Is the survivor homebound?*

Yes

If the survivor is not homebound, BIANK requires a visit or phone call to one of the local day programs (verified by picture or confirmation from day program), prior to approving in-home care. I understand this clause.*

Yes

Survivor is homebound

Does the survivor receive financial aid from any of the Brain Injury Waivers? (ABI/ABI-LTC, Home & Community Based, or the Michelle P. Waiver). Unfortunately, those who receive services from a waiver will not qualify for the Respite Assistance Program.*

Yes

What county does the survivor live in?*

Please upload proof of brain injury from a medical provider*

Application Attestation

I hereby affirm that all information provided in this application is current, complete, and accurate to the best of my knowledge.

I understand that if the survivor becomes eligible for services under any applicable waiver program, financial assistance through BIANK's Respite Program will be discontinued.

I further acknowledge my responsibility to promptly notify BIANK should the survivor qualify for such waiver services.

I understand if services are not used, applicant will no longer qualify for the Respite Program, in order to allow funding for future applicants.

Signature*

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