TABI mini-grant application Step 1 of 8 12% 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. The maximum amount allowed per year (Fiscal year July-June) is $2,500 with a max of $5,000 over a 5-year period. 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 need assistance.Verification of DiagnosisIn 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.pdfDo 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*Max. file size: 20 MB.Please upload the Verification of Diagnosis form your health care professional completed on your behalf. Traumatic & Acquired Brain Injury Mini-grant ProgramApplicant Name* First Last Date of Birth* MM slash DD slash YYYY Age*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Have you applied for a TABI mini-grant before?* Yes No Have you received a TABI mini-grant before?* Yes No Are you currently receiving Medicaid or Medicare?* Yes No I am currently receiving:* Medicaid Medicare Do you have private insurance?* Yes No Has this request been denied by your private insurance?* Yes No Certification statementCertification Statement* I agree to the Certification StatementI have no funds personally to make this purchase. I verify that there are no other programs available to fund this request, and acknowledge that SDS may request verification in the form of denied applications. I also give permission for the mini-grant contractor to contact me and/or the person completing the form, as indicated below.Signature* Please type your name to verify your consent to the Certification Statement.Amount requested for equipment and/or services to meet the following needs:*Equipment and/or services needed* Medical (includes vision and hearing) Physical / occupational / speech therapy Assistive or adaptive equipment Dental Housing Employment Psychological Home modifications Transportation Other equipment and/or service need Describe equipment/services requested.*Attach supporting documentationE.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 Select files Max. file size: 20 MB, Max. files: 3. 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 documentationMax. file size: 50 MB.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 formName* First Last Relationship to applicant* Phone*Email* Referring agency - Optional InformationThis 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 InformationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneTelephone: 907-274-2824 Fax: 907-274-2826 Information to Be Released:From (date) MM slash DD slash YYYY To (date) 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: 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 InformationThis information is not required to complete the TABI mini-grant application but may help us with processing your application more effectively if provided.Guardian InformationIf applicable, please provide information on your court-appointed conservator or guardian.Name First Last Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneEmail 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.Max. file size: 50 MB.