Form W-1130 "Acquired Brain Injury (Abi) Waiver Request Form" - Connecticut

What Is Form W-1130?

This is a legal form that was released by the Connecticut State Department of Social Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Connecticut State Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form W-1130 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

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Download Form W-1130 "Acquired Brain Injury (Abi) Waiver Request Form" - Connecticut

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W-1130
STATE OF CONNECTICUT
(Rev. 7/16)
DEPARTMENT OF SOCIAL SERVICES
ACQUIRED BRAIN INJURY (ABI) WAIVER REQUEST FORM
1.
Personal Data
Name
Social Security #
Address
No.
Street
Apt. No.
City
State
Zip Code
Telephone
(
)
Age
Date of Birth
(month)
(day)
(year)
Single
Married
Widowed
Divorced
Contact person if other than yourself:
Name
Telephone
(
)
Address
No.
Street
Apt. No.
City
State
Zip Code
Relationship
Conservator of Person
Conservator of Estate
(check all that apply)
Other (specify)
2.
ABI Information
Do you have an acquired brain injury?
Yes
No
If Yes, please indicate date of injury
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
W-1130
STATE OF CONNECTICUT
(Rev. 7/16)
DEPARTMENT OF SOCIAL SERVICES
ACQUIRED BRAIN INJURY (ABI) WAIVER REQUEST FORM
1.
Personal Data
Name
Social Security #
Address
No.
Street
Apt. No.
City
State
Zip Code
Telephone
(
)
Age
Date of Birth
(month)
(day)
(year)
Single
Married
Widowed
Divorced
Contact person if other than yourself:
Name
Telephone
(
)
Address
No.
Street
Apt. No.
City
State
Zip Code
Relationship
Conservator of Person
Conservator of Estate
(check all that apply)
Other (specify)
2.
ABI Information
Do you have an acquired brain injury?
Yes
No
If Yes, please indicate date of injury
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
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:
Amount
Source
My total assets (for example, cash, bank accounts, IRAs, life insurance, annuities, stocks, bonds,
motor vehicles, property, etc.)
Amount
Source
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
55 Farmington Avenue
Hartford, CT 06105-3730
Attention: Community Options Unit
th
9
Floor
Persons who are deaf or hard of hearing and have a TTD/TTY device can contact DSS at 1-800-
842-4524. Persons who are blind or visually impaired, can contact DSS at 1-860-424-5040.
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