Application for Services

Information About the Person Needing Services

Provide the name and address of the Doctor(s) and/or Hospital(s) who provided treatment for your brain injury.

Other community services being received. Check all that apply.

Insurance

Has the person needing services had any of the following?

Financial Information

Financial information is needed for the following reasons:

1. To determine the person’s ability to participate in payment for services offered which may require payment.

2. To better understand and communicate with donors about the financial needs of our clients. If this information is provided to a donor, it does not include client names.

How did you hear about Brain Injury Services? Please list contact information.

If this is a referral, please complete all fields below, including email address.

Consent to Exchange Information

I understand that different agencies provide different services and benefits. Each agency must have specific

information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain

information, so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

Consent to Exchange Information

I want the staff of Brain Injury Solutions, 3904 Franklin rd, Suite B, Roanoke, VA 24014-3039,

AND

Name and address of the referring agency and the following other agencies to be able to exchange this information.

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agencies from sharing information after they know my

consent has been withdrawn. I have the right to know what information about me has been shared, and why, when, and with whom It was shared. If I ask, each agency will show me this information.

I want all the agencies to accept a copy of this form as a valid consent to share information. If I do not sign this form, information will not be shared,

and I will have to contact each agency individually to give them information about me that they need.

Note: This Information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2.

Brain Injury Solutions is not a healthcare provider

Medical Records and other documents can be uploaded below.

By signing below the applicant or family has given permission for, and approval of, coordination of community services, and permission for the following: Brain Injury Solutions may communicate information about the applicant with appropriate providers when a sentinel event occurs. Brain Injury Solutions may, at its discretion, conduct a criminal background check on the applicant.

By signing this application, you acknowledge that Brain Injury Solutions has the right to store personally identifiable information in their secured, electronic case management system.

Brain Injury Solutions also reserves the right to share certain necessary, required information, for the purposes of program and financial auditing, contract compliance monitoring, and management and outcome reporting with its funding partner, the Department for Aging and Rehabilitative Services (DARS). This specific information is stored in a secure location maintained by the Department for Aging and Rehabilitative Services (