Get the free TBI Waiver Referral Form - Headway of WNY - headwayofwny

New York State Department of Health Division of Home and Community Based Services REFERRAL FORM HOME AND COMMUNITY BASED SERVICES MEDICAID WAIVER TRAUMATIC BRAIN INJURY (TBI) Transferred from: Referral

How to fill out tbi waiver referral form

How to fill out the TBI waiver referral form:

1. It is important to carefully read the instructions provided with the form to ensure accurate completion.
2. Begin by filling out the personal information section, including your full name, contact details, and any other required information such as date of birth or social security number.
3. Provide information about your current living situation, such as whether you reside in a nursing facility or your own home.
4. Indicate any medical conditions or disabilities you have, especially those related to traumatic brain injury.
5. Describe your current level of functioning and any limitations you experience as a result of the brain injury.
6. Include information about any current services or supports you are receiving, such as therapy or assistance with daily living activities.
7. If applicable, provide details about any previous or ongoing legal involvement, such as guardianship or conservatorship.
8. Make sure to sign and date the form, adhering to any additional requirements specified in the instructions.
9. It is important to review the completed form for accuracy and completeness before submission.

Who needs the TBI waiver referral form:

1. Individuals who have experienced a traumatic brain injury and require additional supports and services may need to fill out the TBI waiver referral form.
2. This form is typically required for individuals seeking access to the Traumatic Brain Injury (TBI) waiver program, which provides home and community-based services to help individuals with TBI live independently or with the support they need.
3. Health providers, case managers, or individuals themselves may initiate the referral process and complete the form to determine eligibility for the TBI waiver program.

For pdfFiller’s FAQs

What is tbi waiver referral form?

The TBI waiver referral form is a document used to refer individuals who have experienced a traumatic brain injury to the TBI waiver program for services and support.

Who is required to file tbi waiver referral form?

Healthcare professionals, social workers, or individuals themselves can file the TBI waiver referral form.

How to fill out tbi waiver referral form?

To fill out the TBI waiver referral form, one must provide the individual's personal information, medical history, and details about the traumatic brain injury.

What is the purpose of tbi waiver referral form?

The purpose of the TBI waiver referral form is to assess eligibility for the TBI waiver program and provide necessary services and support to individuals with traumatic brain injuries.

What information must be reported on tbi waiver referral form?

The TBI waiver referral form must include the individual's demographic information, medical history, details of the traumatic brain injury, and the need for services and support.

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