Navigating the complexities of healthcare and support services for individuals with an acquired brain injury (ABI) in Connecticut requires understanding various forms and procedures, among which the W-1130 form is crucial. Issued by the Department of Social Services, this form plays a pivotal role for residents seeking to access the ABI Waiver. The waiver is designed as an alternative to institutional care, offering individuals the choice to live more independently within the community. It encapsulates a broad spectrum of information, starting with personal data, extending through specifics about the ABI diagnosis, preferences regarding living arrangements, and financial details including both income and assets. Additionally, the form addresses Medicaid and Medicare information, crucial for determining eligibility and the level of support an individual can receive. Completing and submitting the W-1130 form marks a significant step for Connecticut residents with ABIs towards achieving a greater quality of life, aligning services and support with their unique needs and preferences. This comprehensive yet concise document also emphasizes the state's commitment to providing tailored healthcare solutions, ensuring that every citizen has the opportunity to live with dignity and independence.
| Question | Answer |
|---|---|
| Form Name | Connecticut Form W 1130 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | w1130ABIRequest Form acquired brain injury abi waiver request form |
STATE OF CONNECTICUT |
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(Rev. 2/07) |
DEPARTMENT OF SOCIAL SERVICES |
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ACQUIRED BRAIN INJURY (ABI) WAIVER REQUEST FORM |
1.Personal Data
Name |
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Social Security # |
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Address |
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No. |
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Telephone ( |
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Age |
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Single |
Married |
Widowed |
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State |
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Zip Code |
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Date of Birth |
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(year) |
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Divorced |
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Contact person if other than yourself:
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Telephone |
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Apt. No. |
City
Relationship
(check all that apply)
State
Conservator of Person
Other (specify)
Zip Code
Conservator of Estate
2.ABI Information
Do you have an acquired brain injury?
If Yes, please indicate date of injury |
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Yes
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No
and diagnosis
3.Freedom of Choice - Please read the following and check the box that indicates your choice
If possible, I would prefer to live in the community rather than a nursing home or other institutional setting.
I would prefer to live in a nursing home or other similar setting.
4.Medicaid (Title 19) and Medicare Information
Please check the blocks that apply to you:
I am receiving Medicare benefits (enter claim number)
I am receiving Medicaid/Title 19 benefits (enter case number)
I have a Medicaid "Spenddown" (enter case number, if known)
I have applied for Medicaid benefits but have not received a decision
I have not applied for Medicaid benefits
THIS INFORMATION IS AVAILABLE IN ALTERNATE FORMATS. PHONE (800)
(800)
5.Financial Data
My total monthly income (for example, Social Security, SSI, disability benefits, pension benefits, Workers Compensation, wages, contributions, income from interest or dividends, etc.) is:
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My total assets (for example, cash, bank accounts, IRAs, life insurance, annuities, stocks, bonds, motor vehicles, property, etc.)
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Source |
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Signature of Applicant |
Date |
Signature of Conservator or Other Representative |
Date |
Typed or Printed Name of Conservator or Other Representative |
Date |
Return This Form To:
Department of Social Services
25 Sigourney Street
Hartford, CT
Attention: Social Work Services
10th Floor