BRAIN HEALTH MATTERS

Application for Benefits

APPLICANT INFORMATION
Last Name First M.I. Date

Street Address Apartment/Unit #

City State ZIP

Phone E-mail Address

DOB

MENTAL HEALTH PROVIDER INFORMATION

Last Name First M.I.

Street Address Apartment/Unit #

City State ZIP

Phone E-mail Address

INSURANCE INFORMATION
Company Group #

Deductible? CoPay?

Policy Holder if different from Applicant: ID#

Last Name First M.I. Date

Street Address Apartment/Unit #

City State ZIP

Phone E-mail Address

DOB

EMPLOYMENT INFORMATION

Company Phone

Address Supervisor

From To

Please attach last 2 months pay stubs. If self-employed please provide a copy of your most recent 1099

MILITARY SERVICE

Branch From To

Have you visited a VA Hospital in the past year? Y N

PLEASE PROVIDE A SUMMARY OF WHY YOU ARE APPLYING FOR ASSISTANCE

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge and give permission to contact my provider for additional
information.

Signature Date

Signature of Parent or Guardian if a minor

The recipient will hold the this information in confidence and will not disclose it to any person or entity without the prior written
consent of the owner.

Please print this application, fill it out, and mail it (along with the financial information requested) to:

Brain Health Matters

P.O Box 16142
Rocky River, OH 44116

For questions on filling out this application please contact us through one of the following:
- brainhealthmatters.org
-ourbhm@gmail.com
or
-440.498.1870