Back

Home
About Me
Get Involved
Our Vision
Shop
More

MCM Brain Injury Foundation

Home
Grant Application

Grant Application

If you have any questions, please contact us at themcmfoundation@gmail.com

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Upload Proof of Identity(Required)

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Please provide one of the following documents: Driver’s License, State ID, Official Government Correspondence, or a Recent Utility Bill.

Is someone filling out this form on your behalf?(Required)

Yes

Person filling out this form, if different from the Applicant(Required)

Legal Guardian / Parent / Other (please specify if “Other”):

Upload documentation of power of attorney or legal guardian(Required)

Max. file size: 5 MB.

Medical Information

Date of TBI occurrence(Required)

Month

Day

Year

Cause of TBI(Required)

Treatment received for TBI(Required)

HIPAA Release Form

Please download the HIPAA Release Form, fill it out, sign, scan as a PDF, and upload the completed document below.

Download HIPAA Release Form

Upload HIPAA Release Form(Required)

Accepted file types: pdf, Max. file size: 5 MB.

By uploading the HIPAA Release Form, you authorize MCM Brain Injury Foundation to access and review your submitted health record information.

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

Authorization/Consent(Required)

You authorize MCM Brain Injury Foundation to access and review your submitted health information.

Yes

Agree to continue(Required)

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.

Name(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Medical Records

Upload Files(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

Financial Information

Annual Income (for applicants 18 years or younger, income of parents or guardians. For married applicants, total combined marital income)(Required)

You have indicated you have $0 income. How do you pay your bills?(Required)

Wages ($). If not received, enter 0.(Required)

How Often?(Required)

Social Security ($). If not relevant to you, enter 0.(Required)

How Often?(Required)

Alimony Received ($). If not relevant to you, enter 0.(Required)

How Often?(Required)

Worker's Compensation / Disability ($). If not relevant to you, enter 0.(Required)

How Often?(Required)

Other Income ($). If not relevant to you, enter 0.(Required)

How Often?(Required)

Have you received a settlement or civil judgement made in connection to your TBI?(Required)

Yes

Do not know

Type of Settlement(Required)

Docket Number(Required)

Amount of settlement ($).(Required)

Attorney Name(Required)

Attorney Email(Required)

Attorney Phone(Required)

Attorney Address(Required)

Are there any pending claims such as, lawsuits, divorce settlements, inheritance, accident claims, medical malpractice, or other claims?(Required)

Yes

Do not know

If yes, please provide details of the claims, including but not limited to, the date monies were received and the type of claim.(Required)

Do you have any liquid assets $100,000 or more?(Required)

Yes

Additional savings account?(Required)

Yes

Savings Amount(Required)

Additional checking account?(Required)

Yes

Checking Amount(Required)

Do you receive direct express?(Required)

Yes

Do you own or have any interest in whole or part, any properties other than your own private residence (including but not limited to other homes, land, and buildings?)(Required)

Yes

Health Insurance Information

Do you have health insurance?(Required)

Yes

Type of Insurance(Required)

Private

Medicaid Managed Care Organization (MCO)

Medicare

Dental

Vision

Other

Private Policy Name(Required)

Private Policy Number(Required)

Medicare Part A Date Eligible(Required)

Month

Day

Year

Medicare Part B Date Eligible(Required)

Month

Day

Year

Medicare Part C Date Eligible(Required)

Month

Day

Year

Medicare Part D Date Eligible(Required)

Month

Day

Year

Medicaid Managed Care Organization (MCO) Name(Required)

Medicaid Managed Care Organization (MCO) Policy Number(Required)

Dental Policy Name(Required)

Dental Policy Number(Required)

Vision Policy Name(Required)

Vision Policy Number(Required)

Other, please explain.(Required)

We are a 501(c)(3) nonprofit organization.

Home
About Us
Our Vision
Get Involved
TBI Resources
Blog & Events
Make a Donation
Grant Application
Shop
Golf Outing 2025

Cart
Checkout
My Account
Track Order
Lost Password
Contact Us

Receive updates and ways to get involved.

Follow us on Instagram

Stay connected with us on Instagram @themcmfoundation for updates, events, behind-the-scenes moments, and more!

Follow on Instagram

Facebook-f
X-twitter
Instagram

Privacy Policy
Accessibility Statement