Referral, Application and Eligibility Determination Process

(1) Any person, agency or organization may refer an individual by contacting SHIP. SHIP shall send a letter to the referred individual, which shall include an application and release of information forms. (2) The eligibility determination process begins withthe submission of an application form signed by the individual applying for services or their court-appointed guardian. A copy of any applicable Massachusetts guardianship order must be included as well as copies of any authorizations allowing persons other than the individual to act on their behalf such as conservatorship, power of attorney, and representative payee. (3) From the information obtained from the completed application, SHIP shall collect the medicaland related records necessary for an eligibility determination. (4) The documentation that is required bySHIP shallbe hospital or medical records that specifically document the occurrence of a traumatic brain injury and/or treatment of a head injury at the time the traumatic brain injury reportedly occurred. In the event that these records have been destroyed or the hospital has no record of the applicant being seen or the applicant does not remember when and where they were treated (a) the following requirements shall be substituted: 1. A report completed at the time of the injury which specifically documents damage related to traumatic brain injury; or 2. An EMT report, a police report, a report recording domestic violence or military service records which document the injury when it occurred; or 3. Documentation of pathophysiological sequelae which are diagnosis specific, e.g. Shaken Baby Syndrome and Dementia Pugilistica. (b) The applicant shall be notified that SHIP cannot access hospital or medical records and requires any of the requirements set forth in 107 CMR 12.03(4)(a)1. through 3. to substantiate their traumatic brain injury. The applicant shall be given 90 days to submit these materials. (c) If the applicant is unable to provide any of these documents, their application shall be considered incomplete and theycanreapplyfor SHIP services at any time in the future if they are able to acquire the necessary records. 12.03: continued (5) The SHIP neuropsychology consultant shall conduct a comprehensive diagnostic review of all documents received by SHIP which includes: a review of the nature and cause of the brain injury; a review of the nature and extentofanyother disabling conditions or complications, e.g. physical injuries, psychiatric illness or substance abuse. In the event that eligibility cannot be determined solely on the information set forth in 107 CMR 12.03(5), SHIP may require: (a) completion of a functional status assessment form; and/or (b) a neuropsychological assessment; and/or (c) an in person interview with the applicant. (6) Applicants/guardians shall be notified in writing of the eligibility or ineligibility decision. An ineligibility determination may be appealed through the appeal procedure set forth 107 CMR 12.09.