Grant Application

I agree to the release of the medical information below to the Traumatic Brain Injury Fund for the purposes of determining eligibility. I understand that the TBI fund reserves the right to contact listed physician for clarification of this information, and that medical information is protected under the Health Insurance Portability and Accountability Act (HIPAA). By signing below, I certify that the information provided is true, correct and complete to the best of my knowledge. I also certify that I have read and understand my responsibilities under this fund.

MCM Brain Injury Foundation

Medical Information

HIPAA Release Form

HIPAA Compliant Authorization for the Release of Patient Information Pursuant to 45 CFR 164.508

Medical Records

Financial Information

Health Insurance Information

Receive updates and ways to get involved.

Follow us on Instagram