TABI mini-grant application

Step 1 of 8

This TABI Mini-Grant application is designed to allow for completion from start to finish online.

Before proceeding, please have the following documents handy:
- Verification of Diagnosis
- Estimates, bills, invoices or some document showing the item or services you are asking for. Please note that the amount requested should match the amount on invoices. These documents can be scanned or simply screenshots as long as they can be clearly read. Also, if you are sending an estimate, please make sure the pricing is good for 60 days as the grant process can take that long.
- We do not need medical records or any other personal documents that do are not asked for in the process. Our office will contact you should we need something else.
The grant cycle is monthly and we take applications from the start of a month to the last day of the month. Our committee meets once a month and usually has a decision by 10th of the month and items/services are aid for by the 15th in most cases.

We will contact you by phone and/or email once a decision is made. You will also receive a letter stating the decision and, if applicable, a reason for denial.

Our office does its best to communicate any concerns to make sure applications are complete as incomplete applications are NOT considered by the committee. While the online process has eliminated many reasons for incomplete applications Common reasons for incomplete applications are usually caused by:
- No verification of diagnosis on file
- Incomplete answers on application
- Missing information about items/services needed
We will continue to improve the process as time goes on and we appreciate your patience with this new online application.

Please contact is at [email protected] or 907-274-2824 if you eed assistance.
Verification of Diagnosis
In order to complete the TABI mini-grant application you will first need to obtain a Verification of Diagnosis from your healthcare professional.
The form may be downloaded at the following URL: https://alaskabraininjury.net/VOD.pdf
Do you already have a Verification of Diagnosis on file with Alaska Brain Injury Network?*
- Yes, I confirm I already have a Verification of Diagnosis on file with Alaska Brain Injury Network.
- No
Verification of Diagnosis form*
Please upload the Verification of Diagnosis form your health care professional completed on your behalf.

Traumatic & Acquired Brain Injury Mini-grant Program
Applicant Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*

Describe equipment/services requested.*
Attach supporting documentation
E.g., two estimates from separate vendors, catalog page/order, or prescription from a licensed health care professional. Include the cost of shipping and enough detail to facilitate the purchase if awarded the mini-grant.
Supporting documents*
Drop files here or

Statement of Injury and Circumstances*
Please provide a written explanation, including the date and circumstances, of your injury.
Describe the essential need which the equipment/services will address.*
Provide additional documented evidence of need, if available. List all other resources that were explored in addition to the TABI mini-grant.
Supporting documentation
Describe how the equipment/services will increase independent functioning and integration in the community.*
What outcome is expected if funding is received? What outcome will take place if funding is not received?
Person completing form
Name*
First Last
Relationship to applicant*
Phone*
Email*
Referring agency - Optional Information
This information is not required to complete the TABI mini-grant application but may help us with processing your application more effectively if provided.
Referring provider agency
Agency contact
Agency Phone

Authorization for Release of Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Telephone: 907-274-2824 Fax: 907-274-2826
Information to Be Released:
From (date)
Date Format: MM slash DD slash YYYY
To (date)
Date Format: MM slash DD slash YYYY
Description of information to be released:
The purpose of the release of this information is:
Consent to release information
I agree.
I hereby authorize the use or disclosure of my health care and/or other information as described above. I understand that this authorization is voluntary. I understand that my records may contain sensitive information. I understand that I may revoke this authorization at any time by notifying the individuals(s) or organizations releasing this information in writing. If I do it won't have any affect on actions taken on this authorization by my revocation was received. To the extent that this information is required to remain confidential by federal or state law, the recipient of this information must continue to keep this information confidential. I understand that I may request a copy of this signed authorization.
This authorization expires on the following date:
Date Format: MM slash DD slash YYYY
Name of Individual or Personal Representative
First Last
Name of Individual or Personal Representative Witness
First Last
Description of Personal Representative's authority

Additional Supporting Documentation - Optional Information
This information is not required to complete the TABI mini-grant application but may help us with processing your application more effectively if provided.
Guardian Information
If applicable, please provide information on your court-appointed conservator or guardian.
Name
First Last
Mailing Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Email
Preferred contact
- Mail
- Phone
- Email
Guardianship Type
- Public Guardian (OPA)
- Full (legal) Guardian
- Power of Attorney (POA)
- Representative payee
- Conservatorship
Please attach a copy of court documents establishing guardianship.

TABI mini-grant application

Step 1 of 8

Verification of Diagnosis

Traumatic & Acquired Brain Injury Mini-grant Program

Certification statement

Attach supporting documentation

Person completing form

Referring agency - Optional Information

Authorization for Release of Information

Information to Be Released:

Additional Supporting Documentation - Optional Information