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STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES W-1130 (Rev. 2/07) ACQUIRED BRAIN INJURY (ABI) WAIVER REQUEST FORM 1. Personal Data Name Social Security # Address No. Street Apt. No. City State

How to fill out acquired brain injury abi

How to fill out acquired brain injury (ABI):

1. Begin by gathering all relevant medical and personal information related to the ABI. This may include medical reports, test results, and documentation of any therapy or treatment received.
2. Fill out the patient's personal information accurately, including their name, date of birth, and contact details.
3. Provide a detailed description of the ABI, including the date of the injury, the circumstances surrounding it, and any known causes or contributing factors.
4. Specify the type of ABI, such as traumatic brain injury (TBI) or non-traumatic brain injury (NTBI), and any specific medical diagnoses related to the ABI.
5. Document all symptoms and impairments resulting from the ABI, including cognitive, physical, and emotional challenges experienced. This may involve providing specific examples or using standardized medical terminology.
6. Include details of any medical treatments or rehabilitative interventions received, such as surgeries, therapy sessions, or assistive devices used. Mention the duration and frequency of these interventions if applicable.
7. Describe any ongoing medical care or supportive services required due to the ABI, such as medication management, regular doctor visits, or assistance with daily activities.
8. If available, attach any supporting documentation, such as medical reports, test results, or letters from healthcare professionals, to provide additional evidence regarding the ABI and its impact.
9. Review the completed ABI form for accuracy and completeness before submitting it to the relevant authority or organization.

Who needs acquired brain injury (ABI):

1. Individuals who have suffered a traumatic brain injury (TBI) due to accidents, falls, sports-related injuries, or assaults.
2. People with non-traumatic brain injuries (NTBI) caused by strokes, brain tumors, infections, or other medical conditions.
3. Caregivers and family members of individuals with ABI who may need to fill out the form on their behalf in order to access appropriate medical, legal, or rehabilitative services.
4. Healthcare professionals, including doctors, therapists, and psychologists, who may require ABI information as part of their assessment, diagnosis, and treatment process.
5. Insurance providers or legal professionals involved in claims or legal proceedings related to the ABI.

For pdfFiller’s FAQs

What is acquired brain injury abi?

Acquired Brain Injury (ABI) refers to any damage to the brain that occurs after birth, which is not hereditary, congenital, degenerative, or caused by birth trauma.

Who is required to file acquired brain injury abi?

Healthcare providers, hospitals, and other medical facilities are required to file acquired brain injury data.

How to fill out acquired brain injury abi?

Acquired brain injury data can be filled out using specific forms provided by the appropriate health authorities.

What is the purpose of acquired brain injury abi?

The purpose of acquired brain injury abi is to track and monitor incidents of brain injuries for research, prevention, and treatment purposes.

What information must be reported on acquired brain injury abi?

Information such as the type of brain injury, cause, location, and demographics of the individual must be reported on acquired brain injury forms.

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