COLORADO TRAUMATIC BRAIN INJURY TRUST FUND

Important Information for First Time Applicants

Thank you for your interest in the Colorado TBI Trust Fund. The following information is provided
to help you decide whether this program is right for you. Please read it carefully before
completing the application. If you have any questions or need assistance, call the Brain
Injury Association of Colorado at 303.355.9969 or toll-free at 888.331.3311.

PROGRAM ELIGIBILITY

 To be eligible for the Colorado TBI Trust Fund, you must meet all the following criteria:
 Have a medically documented traumatic brain injury, resulting in ongoing impairment of
cognitive or physical function (if you need assistance obtaining medical documentation contact
the Brain Injury Association at 303.355.9969 or 888.331.3311),
 Be a resident of Colorado (physically living in the state of Colorado),
 Be lawfully present in the United States (if 18 years of age or older),
 Complete and return the application.
 A traumatic brain injury (TBI) is defined as an injury to the brain caused by an external
force. Causes of TBI include, but are not limited to: falls, motor vehicle-traffic, motorcycle
accident, struck by/against, sporting related injury, assaults, and blast injuries.
 Causes of brain injury that do not qualify for assistance from the TBI Trust Fund are:
anoxia, stroke, aneurysm, congenital abnormality, disease, and surgical intervention.
PROGRAM GUIDELINES

 Eligible applicants will be served on a first come, first serve basis, and only when funds are
available.
 Effective June, 6 2008, a program participant may receive care coordination and purchased
services for one year. At the end of a year of services, the participant may re-apply for an
additional year of care coordination only. Limited funding is only available to use in
the first year of program participation.

CARE COORDINATION
 Care Coordination is the focus of the Colorado TBI Trust Fund Program.
 A Care Coordinator works with an individual to provide information, identify resources,
coordinate services, and develop advocacy skills related to their TBI.
SERVICES
 During your first year of program participation (which starts when you meet with your care
coordinator) you may also be eligible for limited funding for items and/or services discussed
by you and your care coordinator.
 The Trust Fund will not:
 Pay for outstanding bills or bills you have already paid,
 Pay or reimburse you (with exception of approved mileage), or
 Pay for rent, utilities, medications, hospitalizations, institutionalization, or food.
WHERE TO SEND YOUR APPLICATION

Brain Injury Association of Colorado

Colorado TBI Trust Fund Program
4200 West Conejos Pl, Ste 524
Denver, Colorado 80204
Fax: 303.355.9968

Page 1 of 9
Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
 COLORADO TBI TRUST FUND APPLICATION CHECKLIST

Please use this checklist to make sure you have completed and included all necessary information
needed to process the application. Please read each carefully:

Sections 1 thru 6

Section 1: Applicant Information

 All fields are completed.

Section 2: Contact Information

 Representative information is completed (if applicable).
 Applicable documentation is included:
o Power of Attorney,
o Legal Guardianship, or
o Form A: Designation of Personal Representative.

Section 3: Residency Eligibility

 Affidavit is signed and dated for applicants age 18 and over.
 Clear photocopy of documentation is included for all
applicants 18 years of age or older.

Section 4: Medical Eligibility

 Description of injury is completed.
 Medical Documentation is included:
o Medical Records, or
o Form B: Authorization to Release and/or Obtain
Patient Information.

Section 5: Authorization
 Applicant or Authorized Representative has signed and
dated.

Section 6: Notice of Privacy Practices

 Applicant or Authorized Representative has signed and
dated.

Forms A & B

Form A: Designation of Personal Representative

 Unless the representative is Power of Attorney, Legal
Guardian, or custodial parent, this is completed.

Form B: Authorization to Release and/or Obtain Patient Information

 This is completed when an applicant is requesting the TBI
Trust Fund to access Medical Documentation of TBI.

Page 2 of 9
Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
 COLORADO TRAUMATIC BRAIN INJURY TRUST FUND
First Time Application

SECTION 1: APPLICANT INFORMATION (person applying for services)

Last Name First Middle Name

Street Address Apartment #

City State ZIP

Home # Work # County

Cell # E-mail Address

SSN DOB Gender: M F

African American/Black American Indian/Alaskan

Race/Ethnicity Asian Caucasian/White
(Optional) Hispanic/Latino Pacific Islander
Other: ___________________

Military Status YES NO Specify: Active Duty Veteran

If no, would you like

Is English your primary language? YES NO YES NO
an interpreter?

If not English, what is your primary

language?

Have you ever been convicted of a

violent crime or felony? (conviction YES NO If yes, explain:
will not exclude you from program)

Please circle who referred you to the TBI Trust Fund (circle as many that apply):

Primary Care Physician Rehab Hospital Hospital Clinic

Trust Fund Provider Community Provider Community Non-profit Brain Injury Assoc. of CO
Trust Fund Client Denver Options Military Agency Veterans Administration
State Agency Educational Facility Conference/Event Support Group
Other Family Friend Mild TBI Information Card

Please specify: _______________________________________

Page 3 of 9
Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
SECTION 1: APPLICANT INFORMATION (continued)
Do you have a substance abuse or dependence problem requiring treatment and meet at least one of the
following: age 25 or younger; have used methamphetamines and/or Ecstasy in the past 30 days?
Yes No (If yes, you may be eligible for additional funding.)
Have you applied for the following? (check all that apply)
Supplemental Security Income (SSI) Social Security Disability Insurance Income (SSDI)

Do you receive the following? (check all that apply)

Supplemental Security Income (SSI) Social Security Disability Insurance Income (SSDI)
Do you have medical insurance? Yes No Please specify: _______________________
(e.g. Medicaid, Medicare, private)

SECTION 2: CONTACT INFORMATION

Communication about this application and the Colorado Traumatic Brain Injury Trust Fund should be
directed to:

Applicant Only Representative Only Both Applicant & Representative

If you marked Applicant Only, please skip to Section 3 on page 5.

REPRESENTATIVE OR PARENT OF APPLICANT UNDER 18 - CONTACT INFORMATION

Full Name Relationship

Street Address Apt #

City State Zip

Phone # E-mail Address

If you are the parent of an applicant under the age of 18, please skip to Section 4 on page 6.

SUPPORTING DOCUMENTATION

Please mark and include one of the following documents to allow Trust Fund staff to communicate
with the representative:
Power of Attorney
Legal Guardianship
Designation of Personal Representative (Complete Form A)

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Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
SECTION 3: RESIDENCY ELIGIBLITY
LAWFUL PRESENCE IN THE UNITED STATES (for applicants 18 years of age or older)

Effective August 1, 2006, in order to receive benefits provided by the Colorado TBI Trust Fund program, each
eligible applicant 18 years of age or older, must execute an Affidavit stating that he/she is a United States
citizen or legal permanent resident, or is otherwise lawfully present in the United States pursuant to federal law
and provide documentation to verify his/her residency status.

The Affidavit must be executed by each applicant 18 years of age or older:

I swear or affirm under penalty of perjury under the laws of the state of Colorado that this applicant

____________________________________________________________ is (check one):

(name of applicant)

a United States citizen;

a Permanent Resident in the United States; or

lawfully present in the United States pursuant to Federal Law.

I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that I am lawfully present in the United States prior to
receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or
representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second
degree under Colorado Revised Statute 18-8-503 and it shall constitute separate criminal offense each time a
public benefit is fraudulently received.

_________________________________________________ ________________________
(signature of applicant or authorized representative) (date)

DOCUMENTATION

If 18 years or age or older, you must include a clear photocopy of one of the following documents with your
application: Please do not fax a copy of your document due to issues of legibility.

Valid Colorado Driver License/ Identification Card issued by CO Department of Revenue; or

(MILITARY ONLY) Valid Driver License/Identification Card AND military orders stating current stationing in CO; or

Native American Tribal Document.

Legal aliens must also provide a photocopy of immigration documentation containing your Alien Registration
(A-number) or Admission (I-94) Number.

Page 5 of 9
Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
SECTION 4: MEDICAL ELIGIBLITY
A traumatic brain injury (TBI) is defined as an injury to the brain caused by an external force. Causes of TBI
include, but are not limited to: falls, motor vehicle-traffic, motorcycle accident, struck by/against, sporting
related injury, assaults, and blast injuries.
Causes of brain injury not included are: anoxia, stroke, aneurysm, congenital abnormality, disease, and surgical
intervention.
DESCRIPTION OF INJURY
Date(s) of traumatic brain injury: ____ /____ / ____ , ____ / ____ / ____ , ____ / ____ / ____

Cause of traumatic brain injury: Fall Motor Vehicle-traffic Motorcycle accident Assault

Struck by/against Sporting related injury Blast Injury Other: ________________

Briefly describe current symptoms:

Describe assistance needed:

MEDICAL DOCUMENTATION

Eligibility for the Colorado TBI Trust Fund program requires a documented diagnosis of traumatic brain injury,
resulting in ongoing impairment.
The required documentation includes any of the following, but not limited to: hospital discharge summaries,
neuropsychological evaluations, medical records, or physician reports.
Please include this documentation with your application or if you would like Colorado TBI Trust
Fund staff to request your medical information please complete the Authorization to Release
and/or Obtain Patient Information (Complete Form B).
If you need assistance obtaining medical documentation contact the Brain Injury Association at 303.355.9969 or
888.331.3311

SECTION 5: AUTHORIZATION

By signing the application, I swear and attest that the information provided is true and correct to the best of my
knowledge. My signature authorizes the Colorado TBI Trust Fund to:

 Receive reimbursement for funded services if expenses are recovered by a third party, such as lawsuit or
settlement.
 Be held harmless from any and all claims, disputes, liabilities, or cause of action arising out of the
agreement to provide assistance, or the providing of assistance by the Colorado TBI Trust Fund.

________________________________ ___________________________________ ___________

(Applicant’s printed name) (Applicant’s signature) (Date)

OR

________________________________ ___________________________________ ___________

(Parent/Authorized Representative’s printed name) (Parent/Authorized Representative’s signature) (Date)

Page 6 of 9
Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
SECTION 6: PRIVACY PRACTICES
The Colorado Traumatic Brain Injury Trust Fund Program is required to follow the privacy practices described in this Notice. We reserve
the right to change our privacy practices and the terms of this Notice at any time and apply any changes to all medical information we
have. If we do so, we will post a new Notice on our website at www.tbicolorado.org and on the BIAC website at www.biacolorado.org.
You may request a copy of the new Notice by contacting us at 303.355.9969 or 888.331.3311.

YOUR RIGHTS TO PRIVACY:

Your medical information will not be shared and/or disclosed without your permission except as described in this Notice under Disclosures Not
Requiring Your Permission. You may authorize other disclosures by completing an authorization form, and may withdraw this authorization in
writing at any time. You have the right to ask the Colorado TBI Trust Fund Program to:
 Contact you by telephone, fax, mail, or e-mail at a specific number or address;
 Limit the use and/or disclosure of your medical information (we are not required by law to agree to your request);
 Look at or have a copy of any part of your designated record set maintained by the Colorado TBI Trust Fund (you may be charged
processing and/or postal fees for this request);
 Change or add information to your designated record set (original documents may not be changed);
 Provide a list of disclosures of your medical information made after April 14, 2003 (which will not include disclosures for purposed of
treatment/treatment alternatives, payment, health care operations, appointments, or those made to you or with your permission)
You may access your medical information by submitting a request to BIAC’s Colorado TBI Trust Fund Department at 4200 West Conejos Pl, 524,
Denver, CO 80204.
CONFIDENTIALITY PRACTICES AND USES:
The Colorado TBI Trust Fund Program (including agencies contracted to handle administration, application, eligibility, care coordination and
purchase of program services) may access, use and/or share medical information for:
Treatment or Treatment Alternatives – For example, we may use medical information about you to coordinate health care related service, disclose
information to providers who become involved in your care, or notify you about treatment alternatives or services that maybe of interest.
Payment – For example, we may use medical information about you to determine your benefit eligibility or make decisions about purchasing
services.
Health Care Operations – For example, we may use this information to evaluate the performance of your health plan or health care provider.
Appointments – For example, we may use this information to schedule or remind you of appointments.

DISCLOSURES NOT REQUIRING YOUR PERMISSION:

The Colorado TBI Trust Fund Program can make disclosures under the following circumstances without your permission, under court order or law.
Whenever permitted, your will be informed of these disclosures.
Government Agencies and/or organizations Providing Benefits, Services, or Disaster Relief – For example, we may disclose information to the Red
Cross for you to receive benefits during a natural disaster.
Public Health – For example, we may disclose medical information for disease control and prevention, problems with medical products or
medications, or prevent abuse, neglect or domestic violence.
Health Oversight Activities – For example, we may disclose information to approved government agencies such as those responsible for the
Medicaid program, U.S. Department of Health and Human Services or the Office of Civil Rights.
Judicial and Administrative Hearings –For example, we may disclose specific medical information under court order or C.R.S. 27-10.
Law Enforcement Purposes – For example, we may disclose information for law enforcement purposes, such as subpoenas.
Coroners, Medical Examiners, and Funeral Directors - For example, we may disclose information to such professionals who need it to administer
their work.
Organ Donation and Disease Registries - For example, we may disclose medical information to authorized cancer or transplant registries.
Research Purposes- For example, we may disclose information to assist with medical or psychiatric research.
To Avert Serious Threat to Health, Safety, or Emergency Situation - For example, we may disclose information to prevent a serious threat to the
health and safety or an individual or the public.
Specialized Government Functions - For example, we may disclose information for national security purposes or to military authorities if you have
been a member of the armed forces.
Correctional Institutions - We may disclose medical information to correctional facilities to maintain the health, safety, and security of this system.
Workers’ Compensation - We may disclose medical information to programs that provide benefits for work related injuries without regard to fault.
As Otherwise Required By Law
By signing this document, I acknowledge that I have received and reviewed the Colorado Traumatic Brain Injury Trust Fund
Program’s Notice of Privacy Practices.

_____________________________________________ ____ / ____ / ____ _____ - _____ - _______

(Applicant’s printed name) (Date of Birth) (SSN)

_____________________________________________ ________________ ________________

(Applicant’s signature) (Date ) (Time)

_____________________________________________ ________________ ________________

(Parent/Authorized Representative’s signature) (Date ) (Time)
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Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
FORM A: DESIGNATION OF PERSONAL REPRESENTATIVE
(for the Use and Disclosure or Protected Health Information)
The Health Insurance Portability Accountability Act of 1996 states that an individual has the right to have one or
more persons act as a representative to make decisions about the uses and sharing of Protected Health
Information (PHI). The individual can limit the amount of Protected Health Information that the authorized
personal representative(s) can decided about, and the individual can revoke this at any time. The Brain Injury
Association of Colorado (BIAC), in the exercise of professional judgment, can decide that is it not in the best
interest of the individual to treat the person as the individual’s personal representative.
(45 C.F.R & 164.502 (g))
DESIGNATION OF PERSONAL REPRESENTATIVE:

______________________________________ hereby names the following person to act as authorized

(Name of applicant or legal guardian)

Personal Representative with respect to decisions involving the use and/or sharing of Personal Health

Information that pertains to ____________________________________:

(Name of applicant)

_____________________________________ _______________________________
(Name of Designated Personal Representative) (Relationship to applicant)

LIMITS TO THE AMOUNT OF INFORMATION PROVIDED (please check one):

_____ The above named Personal Representative is to be given all of the privileges that would be given to
the patient with respect to Protected Health Information.
______ The above named person is acting as the patient’s Designated Personal Representative ONLY for
the following functions:

_____________________________________________________________________________________
(List functions here)

This designation may be canceled at any time by contacting the Brain Injury Association of Colorado and
arranging to sign the Revocation Section at the bottom of this form. The cancellation can only apply to future
disclosures or actions regarding the patient’s Protected Health Information and cannot cancel actions taken or
disclosures made while the designation was in effect.

___________________________________ __________________________________
(Applicant’s printed name) (Applicant’s signature)

____________ ____________ ____ / ____ / ____ _____ - _____ - _______

(Date) (Time) (Date of Birth) (Phone Number)

REVOCATION SECTION:
I no longer authorize the above named person to act as my Personal Representative.

_______________________________________________ ________________ ______________

(Applicant’s signature) (Date) (Time)

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Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)
FORM B: AUTHORIZATION TO RELEASE AND/OR OBTAIN INFORMATION
OBTAIN FROM: RELEASE TO:

_____________________________________ Brain Injury Association of Colorado

(Name)
Colorado TBI Trust Fund Program
_____________________________________ 4200 West Conejos Pl, Ste 524
(Address) Denver, Colorado 80204
_____________________________________ Telephone: 303.355.9969
(City) (State) (Zip) Toll-Free: 888.331.3311
_____________________________________ Facsimile: 303.355.9968
(Phone) (Fax)

IDENTIFYING INFORMATION: (person applying for the Colorado TBI Trust Fund Program)

________________________________________ ____ / ____ / ____ ____ - ____ - ______

(Name) (Date of Birth) (SSN)

SPECIFIC INFORMATION REQUESTED:

Medical Documentation of traumatic brain injury diagnosis including discharge summaries, physicians’ reports,
and neuropsychological assessments from: ________________________________________
(Dates of treatment or assessment)
THE ABOVE INFORMATION IS TO BE USED FOR:
Eligibility determination, care coordination, and services for the Colorado TBI Trust Fund Program.
I understand that a copy or facsimile of this authorization is to be considered as valid as the original and that this authorization will expire in 365
days from the date of signature. I also understand that I may revoke this authorization at any time and that I will be asked to sign the
Revocation Section on the bottom of this form. I further understand that any action taken on this authorization prior to the rescinded date is
legal and binding.

I understand that my information may be re-disclosed by the recipient of this information to the Care Coordination Agency if I am determined
eligible for the Colorado TBI Trust Fund Program. However, if this information is protected by the Federal Substance Abuse Confidentiality
Regulations (42 C.F.R., part 2), the recipient may not re-disclose such information without my further written authorization, unless otherwise
provided for by state or federal law.

I understand that if my record contains information relating to HIV infection, AIDS, or AIDS-related conditions, alcohol abuse, drug abuse,
psychological or psychiatric conditions, or genetic testing, this disclosure will include that information. I understand that my signature is
required in order for BIAC to obtain all or part of my medical records to determine my eligibility for the Colorado TBI Trust Fund Program. I also
understand that I may refuse to sign this authorization and that my refusal to sign may affect BIAC’s ability to determine my eligibility for the
Colorado TBI Trust Fund Program. If treatment is research-related, treatment may be denied if authorization is not given. (45 C.F.R. & 164.508)

I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it
accurately reflects my wishes.

__________________________ _______ ______ ____________________________ _______ _____

(Patient’s signature) (Date) (Time) OR (Authorized representative’s signature) (Date) (Time)

___________________________________________ ___________________________________________
(Address) (Relationship to patient)

____________________________ _____________ _______________________

(City, State, Zip) (Phone) (Phone)

REVOCATION SECTION:
I no longer authorize the above named parties to release and/or obtain my Protected Health Information.
_______________________________________________ ________________ ______________
(Signature of patient or authorized representative) (Date) (Time)

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Colorado Traumatic Brain Injury Trust Fund Application (Rev 8/10)