Download Application for Brain Injury Fund Assistance 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Applicant Contact Information section. Enter your name, telephone number, street address, mailing address (if different), email address, city, state, and ZIP code.
3. In the Authorized Representative section, indicate if you want someone to represent you by checking 'Yes' or 'No'. If applicable, provide your representative's name and email address.
4. Complete the Demographic & Financial Information section. Select your gender and race/ethnicity. Provide details about your income source and total liquid resources.
5. Fill in the Health Insurance Information with the policy holder's name, insurance company, who is covered under the policy, and the policy number.
6. In the Source of Referral section, specify how you found out about this program.
7. Confirm your eligibility as a Delaware resident and provide details regarding your brain injury diagnosis along with any required documentation.
8. Select desired services from the list provided and indicate any estimated costs if known.
9. Answer questions regarding availability of services through DHSS and provide information about any case manager if applicable.
10. Finally, read through the Acknowledgment & Signature section carefully. Sign electronically where indicated and ensure all required fields are completed before selecting ‘SUBMIT’ to return your application.

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