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INSTRUCTIONS TO APPLY FOR A SENIOR ANSWERS AND SERVICES HEARING GRANTPLEASE READ BEFORE FILLING OUT THE ENCLOSED FORM.
Call 303-333-3482 if you have questions.
Older adults age 60 and over who live in Adams, Arapahoe, Broomfield, Clear Creek, Denver, Douglas, Gilpin, and Jefferson County may apply for a grant for partial assistance with hearing aids and an exam. Priority is given to older adults who are in the greatest economic and social need.
HOW TO APPLY FOR A GRANT:1. Complete the attached Intake Form. 2. Select an audiologist. You may select an audiologist from the list or you may use your own audiologist, but your
audiologist must be willing to accept the grant. Some audiologists may charge more than the amount approved by the Grant.
3. Contact the audiologist and ask if they will accept you as a patient on the Senior Answers and Services Hearing Program.
4. Submit the completed Intake Form to the Senior Answers and Services Hearing Program, 1330 Leyden St #148, Denver CO 80220 (be sure to sign the Intake Form, the Required Acknowledgments Form and the HIPPA -Disclosure Form). INCOMPLETE FORMS WILL BE RETURNED.
5. You will be placed on the waiting list.
WHEN YOU ARE SELECTED TO RECEIVE A GRANT:1. When funding is available, you will receive an Initial Grant Award Letter to make an appointment for an exam.2. After your exam, a treatment plan will be submitted for a grant to cover hearing aids.3. When you receive a Final Grant Award Letter, make another appointment with the audiologist to be fitted for your
hearing aids.4. After you receive your hearing aid, the audiologist will request payment from Senior Answers.5. ANY CHARGES OVER THE AMOUNT APPROVED ARE THE PATIENT’S RESPONSIBILITY.
THINGS TO KNOW:1. The Senior Answers program is NOT insurance.2. Any work that is started prior to the grant award will not be covered by the grant.3. Grants are for a limited time. All work must be completed in a timely fashion.4. There is no guarantee of a grant, as grants are dependent on funding availability.
APPEAL RIGHTS:You will receive a letter indicating that your Intake Form has been received and that you have been placed on the waiting list within six weeks. You may appeal your place on the waiting list if you believe we have inaccurate or incomplete information on the Form.
PLEASE KEEP THIS LETTER AND THE ATTACHED COMPLAINTS PROCEDURES FOR YOUR RECORDS
Funding is made possible through grants from the Older Americans Act through the Denver Regional Council of Governments, Area Agency on Aging, other foundation grants and private donations.
Colorado Gerontological Society 1330 Leyden St, #148, Denver CO 80220 · 303-333-3482 · 303-333-9112 · www.senioranwers.org
Page 2 of 14
Dat
e R
ecei
ved
by C
GS:
Page 3 of 14
2
017
Bas
ic C
onsu
mer
Int
ake
Form
Upd
ated
Feb
ruar
y 10
, 201
7
Bas
ic C
lient
Inf
orm
atio
n:
Dat
e of
Ass
essm
ent:
/
/
*F
irst N
ame:
*L
ast N
ame:
M
iddl
e In
itial
: *D
ate
of B
irth:
/
/
A
ge:
*Gen
der:
M
ale
Fe
mal
e
Oth
er
Are
you
a v
eter
an?
Y
es
No
Wha
t is
your
prim
ary
lang
uage
? *W
hat i
s yo
ur ra
ce?
*Are
you
His
pani
c or
Lat
ino?
Yes
N
o *A
re y
ou v
isua
lly im
paire
d (c
anno
t be
corr
ecte
d w
ith g
lass
es)?
Yes
N
o
Are
you
rece
ivin
g M
edic
aid?
Yes
N
o
*Do
you
live
alon
e?
Yes
N
o A
re y
ou m
arrie
d?
Yes
N
o H
ow m
any
peop
le li
ve in
you
r hou
seho
ld?
Wha
t is
your
mon
thly
inco
me?
W
hat i
s yo
ur m
onth
ly h
ouse
hold
inco
me?
*I
f you
live
alo
ne, i
s yo
ur in
divi
dual
mon
thly
inco
me
belo
w
$1,0
05?
Y
es
No
*If y
ou h
ave
a sp
ouse
or p
artn
er, i
s yo
ur m
onth
ly h
ouse
hold
in
com
e be
low
$1,
353?
Yes
N
o D
o yo
u us
e an
y as
sist
ive
devi
ces?
Yes
N
o If
so,
whi
ch o
nes?
___
____
____
____
____
____
____
____
____
__
*Res
iden
tial S
treet
Add
ress
: M
ailin
g A
ddre
ss -
Stre
et/P
.O. B
ox:
*Apa
rtmen
t or U
nit #
(if a
pplic
able
): M
ailin
g C
ity o
r Tow
n:
*Res
iden
tial C
ity o
r Tow
n:
Mai
ling
Stat
e:
Zip
Cod
e:
*Res
iden
tial S
tate
: Zi
p C
ode:
Em
ail A
ddre
ss:
*C
ount
y of
Res
iden
ce:
*P
rimar
y Ph
one
# (in
clud
ing
area
cod
e):
Seco
ndar
y Ph
one
# (in
clud
ing
area
cod
e):
Emer
genc
y co
ntac
t nam
e:
Rel
atio
nshi
p:
Phon
e N
umbe
r:
Are
you
inte
rest
ed in
rece
ivin
g nu
tritio
n co
unse
ling?
Y
es
No
How
did
you
hea
r abo
ut o
ur s
ervi
ces?
AA
A B
roch
ure
A
AA
New
slet
ter
Cha
nnel
9 S
enio
r Sou
rce
(TV
)
Con
greg
ate
Mea
l Site
Fr
om a
Cur
rent
Clie
nt
Fr
om a
Frie
nd/R
elat
ive
Se
nior
Fai
r
Wal
k-In
W
eb S
ite
Oth
er__
____
____
____
____
____
____
____
____
____
____
___
Do
you
wan
t to
hear
abo
ut o
ther
ser
vice
s?
Yes
N
o If
yes
, how
can
we
cont
act y
ou?
Mai
l
Em
ail
Pho
ne
Whe
n is
the
best
tim
e to
con
tact
you
? Pl
ease
tell
us w
hat s
ervi
ces
you
wou
ld li
ke to
rece
ive:
I h
ave
been
info
rmed
of t
he p
olic
ies
rega
rdin
g vo
lunt
ary
cont
ribu
tions
, com
plai
nt p
roce
dure
s an
d ap
peal
rig
hts.
I am
aw
are
that
in o
rder
to r
ecei
ve r
eque
sted
ser
vice
s, it
may
be
nece
ssar
y to
sha
re in
form
atio
n w
ith o
ther
dep
artm
ents
or
serv
ice
prov
ider
an
d I h
erew
ith g
ive
my
cons
ent t
o do
so.
(I
f fill
ed o
ut b
y as
sess
or o
r vi
a ph
one,
ple
ase
have
ass
esso
r ch
eck
here
and
sig
n be
low
).
Sign
atur
e___
____
____
____
____
____
____
____
____
____
____
____
____
_
Dat
e___
____
____
____
____
Off
ice
use
only
:
Info
rmat
ion
fille
d ou
t by
____
____
____
____
____
___
Dat
e___
____
____
____
____
Page 4 of 14
Act
ivit
ies
of D
aily
Liv
ing
1. I
can
eat
with
out h
elp.
Y
es
No
2. I
can
dre
ss w
ithou
t hel
p
3. I
can
bat
he m
ysel
f with
out h
elp.
4. I
can
use
the
toile
t with
out h
elp.
5. I
can
get
in a
nd o
ut o
f bed
/cha
irs w
ithou
t hel
p.
6. I
can
get
aro
und
insi
de m
y ho
me
with
out h
elp.
7. A
re y
ou c
urre
ntly
rece
ivin
g as
sist
ance
with
any
of t
he a
bove
task
s fr
om a
nyon
e el
se
From
who
m a
re y
our r
ecei
ving
ass
ista
nce?
Phon
e __
____
____
____
____
____
____
__
Inst
rum
enta
l A
ctiv
itie
s of
Dai
ly L
ivin
g
1. I
can
man
age
mon
ey w
ithou
t hel
p.
Yes
N
o
2. I
can
take
car
e of
shop
ping
with
out h
elp.
3. I
can
take
my
med
icat
ions
with
out h
elp.
4. I
can
pre
pare
mea
ls w
ithou
t hel
p.
5. I
can
do
ordi
nary
hou
sew
ork
with
out h
elp.
6. I
can
get
use
the
tele
phon
e w
ithou
t hel
p.
7. I
can
use
tran
spor
tatio
n w
ithou
t hel
p.
From
who
m a
re y
ou re
ceiv
ing
assi
stan
ce?
P
hone
___
____
____
____
____
____
____
_
Your
Nam
e:
Page 5 of 14
Gra
nt A
sses
smen
t Upd
ated
Feb
ruar
y 20
17
You
r Nam
e:
Lang
uage
Abi
lity
(Ple
ase
Chec
k A
ll Th
at A
pply
))
I hav
e di
fficu
lty re
adin
g En
glish
, and
requ
ire h
elp
to d
o so
.
I h
ave
diffi
culty
writ
ing
Engl
ish.
I do
not s
peak
eno
ugh
Engl
ish to
talk
to so
meo
ne w
ho o
nly
spea
ks E
nglis
h an
d ha
ve th
em u
nder
stand
my
need
I d
o no
t und
ersta
nd e
noug
h En
glish
to sp
eak
to a
n En
glish
spea
king
per
son
with
out t
he a
id o
f an
inte
rpre
ter.
R
ace
and/
or E
thni
city
(P
leas
e C
heck
All
That
App
ly)
A
mer
ican
In
dian
Ala
ska
Nat
ive
Asi
an
N
ativ
e H
awai
ian
/ Oth
er
Paci
fic Is
land
er
Whi
te
His
pani
c /
Lat
ino
Oth
er
Bl
ack
/
Afri
can-
Am
eric
an
Coo
rdin
atio
n of
Ben
efits
(
Plea
se C
heck
All
Bene
fits Y
ou C
urre
ntly
Rec
eive
)
Su
pple
men
tal S
ecur
ity In
com
e (S
SI)
Colo
rado
Old
Age
Pen
sion
(OA
P)
Supp
lem
enta
l Nut
ritio
n A
ssist
ance
Pro
gram
(Foo
d St
amps
)
Lo
w-in
com
e En
ergy
Ass
istan
ce P
rogr
am (L
EAP)
Co
lora
do R
ent S
ubsid
y (S
ectio
n 8
or H
UD
hou
sing)
Pr
oper
ty T
ax/R
ent/H
eat R
ebat
e
Te
mpo
rary
Ass
istan
ce fo
r Nee
dy F
amili
es (T
AN
F)
A H
ealth
Mai
nten
ance
Org
aniz
atio
n (H
MO
), Pr
ivat
e Fe
e fo
r Ser
vice
(P
FFS)
, or S
peci
al N
eeds
Pla
n (S
NP)
(ple
ase
indi
cate
the
nam
e)
___
____
____
____
____
____
____
____
____
____
____
____
____
____
_
Colo
rado
Acc
ess (
Long
Ter
m C
are)
Med
icai
d
M
edic
are
Savi
ngs P
rogr
am (M
SP)
Q
ualif
ied
Med
icar
e Be
nefit
(QM
B)
Qua
lifyi
ng In
divi
dual
(QI-
1)
Spec
ial L
ow In
com
e M
edic
are
(SLI
MB)
H
ome
and
Com
mun
ity B
ased
Ser
vice
s (H
CBS)
Ve
tera
ns A
dmin
istra
tion
Bene
fits
TRIC
ARE
H
earin
g A
id In
sura
nce
(ple
ase
spec
ify)
____
____
____
____
____
____
____
____
____
____
Oth
er H
earin
g Be
nefit
(p
leas
e sp
ecify
) __
____
____
____
____
____
____
____
____
____
__
Volu
ntar
y C
ontr
ibut
ions
Th
is pr
ogra
m is
mad
e pos
sible
thro
ugh
a gra
nt fr
om th
e Old
er A
mer
ican
s Act
, thr
ough
the D
enve
r Reg
iona
l Cou
ncil
of G
over
nmen
ts, A
rea
Age
ncy
on A
ging
, oth
er g
rant
s and
priv
ate d
onat
ions
. Any
per
son
rece
ivin
g se
rvic
es sh
all h
ave t
he o
ppor
tuni
ty to
cont
ribut
e tow
ards
the
cost
of th
e ser
vice
. N
o el
igib
le p
erso
nal s
hall
be d
enie
d a s
ervi
ce b
ecau
se o
f the
ir in
abili
ty an
d/or
choi
ce n
ot to
cont
ribut
e. In
divi
dual
s are
no
t cha
rged
a se
t fee
by
the C
olor
ado
Ger
onto
logi
cal S
ocie
ty fo
r any
serv
ices
pro
vide
d. I
ndiv
idua
ls ar
e wel
com
e to
mak
e a v
olun
tary
do
natio
n to
hel
p ot
her s
enio
rs re
ceiv
e ass
istan
ce.
Don
atio
ns fo
r gra
nts o
r oth
er p
roje
cts m
ay b
e sen
t to
Colo
rado
Ger
onto
logi
cal S
ocie
ty,
1330
Ley
den
St #
148,
Den
ver C
O 8
0220
.
Page 6 of 14
Hea
ring
Nee
ds
1.
I hav
e ha
d co
ntin
uing
diff
icul
ty w
ith m
y he
arin
g fo
r mor
e th
an a
yea
r
2.
I h
ave
troub
le h
earin
g ve
ry lo
w o
r ver
y hi
gh p
itche
s
3.
I h
ave
diff
icul
ty h
earin
g m
id-r
ange
pitc
hes
4. I
hav
e a
hist
ory
of e
ar in
fect
ions
5.
I a
void
larg
e cr
owds
bec
ause
I ha
ve d
iffic
ulty
dis
tingu
ishi
ng sp
ecifi
c no
ises
6.
I c
anno
t use
the
tele
phon
e w
ithou
t ass
ista
nce
7. I
hav
e ex
trem
e un
ders
tand
ing
wha
t peo
ple
are
sayi
ng w
hen
we
are
spea
king
face
to fa
ce.
8. I
avo
id so
cial
inte
ract
ions
/act
iviti
es b
ecau
se o
f my
diff
icul
ty h
earin
g
9.
I d
o no
t hav
e a
hear
ing
aid,
or t
he o
ne I
have
is m
ore
than
five
yea
rs o
ld
10. I
hav
e an
ong
oing
hea
lth p
robl
em th
at is
impa
ctin
g m
y ab
ility
to h
ear (
plea
se li
st c
ondi
tions
on
line
belo
w):
_
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Whi
ch e
ar is
suff
erin
g fr
om h
earin
g lo
ss (i
f bot
h, c
heck
bot
h)
Rig
ht E
ar
Left
Ear
Cho
ose A
Hea
ring
Aid
Pro
vide
r
1. C
hoos
e a
hear
ing
aid
prov
ider
or a
udio
logi
st fr
om th
e at
tach
ed li
st (o
r ask
you
r per
sona
l pro
vide
r if h
e/sh
e w
ill a
ccep
t a g
rant
from
our
pro
gram
). 2.
Cal
l the
hea
ring
aid
pro
vide
r or a
udio
logi
st to
ask
if th
ey w
ill ta
ke y
ou a
s a c
lient
with
the
Seni
or A
nsw
ers a
nd S
ervi
ces H
eari
ng P
rogr
am.
Pro
vide
r’s N
ame:
Clin
ic/O
ffic
e N
ame:
A
ddre
ss:
City
, ZIP
Cod
e Ph
one:
Fax
:
You
r Nam
e:
Page 7 of 14
Gra
nt A
sses
smen
t Upd
ated
Feb
ruar
y 20
17
Aut
hori
zatio
n to
Disc
lose
Info
rmat
ion
to th
e C
olor
ado
Ger
onto
logi
cal S
ocie
ty
I vol
unta
rily
auth
oriz
e an
d re
ques
t dis
clos
ure
to th
e C
olor
ado
Ger
onto
logi
cal S
ocie
ty (d
ba S
enio
r Ans
wer
s and
Ser
vice
s) o
f suc
h m
edic
al
info
rmat
ion
as m
ay b
e ne
eded
to p
rovi
de th
e ne
cess
ary
care
for m
e (in
clud
ing
thro
ugh
writ
ten,
spok
en a
nd e
lect
roni
c co
mm
unic
atio
n).
WH
AT
INFO
RM
ATI
ON
WIL
L B
E D
ISC
LOSE
D?
A
ll re
cord
s and
oth
er in
form
atio
n re
gard
ing
hear
ing
asse
ssm
ents
, rec
omm
ende
d tre
atm
ents
, hea
ring
wor
k pe
rfor
med
as w
ell a
s not
per
form
ed o
r de
clin
ed, r
efer
rals
to o
ther
hea
ring
prov
ider
s, an
d co
mpl
icat
ing
med
ical
con
ditio
ns o
r oth
er im
pairm
ents
.
Info
rmat
ion
abou
t how
my
impa
irmen
ts a
ffec
t my
abili
ty to
com
plet
e th
e au
thor
ized
trea
tmen
t pla
n.
WH
O M
AY
DIS
CL
OSE
INFO
RM
ATI
ON
AB
OU
T M
E?
A
ll he
arin
g an
d m
edic
al so
urce
s (he
arin
g cl
inic
s or o
ffice
s, ho
spita
ls, c
linic
s, la
bs, h
earin
g ai
d pr
ovid
ers,
phys
icia
ns, p
sych
olog
ists
, etc
) inc
ludi
ng
men
tal h
ealth
, cor
rect
iona
l, ad
dict
ion
treat
men
t, an
d V
A h
ealth
car
e fa
cilit
ies.
So
cial
wor
kers
, cas
e m
anag
ers,
case
wor
kers
, reh
abili
tatio
n co
unse
lors
, etc
.
Con
sulti
ng d
enta
l pro
vide
rs
Em
ploy
ers
O
ther
s who
may
kno
w a
bout
my
cond
ition
(the
per
son
who
hel
ps m
e fil
l out
this
form
, fam
ily, i
nter
pret
ers,
frie
nds,
neig
hbor
s, p
ublic
offi
cial
s, et
c).
TO
WH
OM
MA
Y IN
FOR
MA
TIO
N B
E D
ISC
LO
SED
?
To th
e C
olor
ado
Ger
onto
logi
cal S
ocie
ty, t
he D
enve
r Reg
iona
l Cou
ncil
of G
over
nmen
ts, a
nd o
ther
age
ncie
s or o
rgan
izat
ions
that
fund
or f
inan
ce th
is
prog
ram
, or w
hich
hel
p to
adm
inis
ter t
his h
earin
g pr
ogra
m, p
rogr
am a
udito
rs, h
earin
g ai
d pr
ovid
ers,
and
othe
r med
ical
pro
fess
iona
ls c
onsu
lted.
T
HE
PU
RPO
SE O
F T
HIS
AU
TH
OR
IZA
TIO
N IS
To d
eter
min
e th
e sp
ecifi
c se
rvic
es fo
r whi
ch th
is p
roje
ct w
ill m
ake
a gr
ant,
and
to m
onito
r the
pro
visi
on o
f ser
vice
s lea
ding
to su
cces
sful
com
plet
ion
of th
e au
thor
ized
trea
tmen
t pla
n, o
r ter
min
atio
n of
trea
tmen
ts a
nd g
rant
. G
EN
ERA
L P
RO
VIS
ION
S
This
aut
horiz
atio
n is
goo
d fo
r fiv
e ye
ars f
rom
the
date
sign
ed (n
ext t
o m
y si
gnat
ure
belo
w).
I a
utho
rize
the
use
of a
pho
toco
py, f
axed
cop
y, o
r oth
er e
lect
roni
c co
py o
f thi
s for
m fo
r the
dis
clos
ure
of th
e in
form
atio
n de
scrib
ed a
bove
.
I may
writ
e to
the
Col
orad
o G
eron
tolo
gica
l Soc
iety
to re
voke
this
aut
horiz
atio
n at
any
tim
e.
Th
e C
olor
ado
Ger
onto
logi
cal S
ocie
ty w
ill g
ive
me
a co
py o
f thi
s aut
horiz
atio
n if
I req
uest
it b
y ph
one
or in
writ
ing.
I hav
e re
ad th
is fo
rm a
nd th
e C
olor
ado
Ger
onto
logi
cal S
ocie
ty’s
priv
acy
polic
y or
had
them
exp
lain
ed to
me
and
agre
e to
the
disc
losu
res.
Com
plet
e th
e in
form
atio
n be
low
if y
ou a
gree
to th
e ab
ove
stat
emen
ts so
we
can
shar
e th
e in
form
atio
n ne
eded
to se
rve
you.
Nam
e:
B
irth
Dat
e
/
/
Add
ress
:
City
/ZIP
: Ph
one:
I
hav
e ca
refu
lly re
ad, u
nder
stan
d an
d ag
ree
to th
e ab
ove
disc
losu
res.
S
IGN
AT
UR
E:
D
AT
E:
You
r Nam
e:
Page 8 of 14
Gra
nt A
sses
smen
t Upd
ated
Feb
ruar
y 20
17
Req
uest
for A
dditi
onal
Ser
vice
s
I u
nder
stand
that
the
Colo
rado
Ger
onto
logi
cal S
ocie
ty n
orm
ally
atte
mpt
s to
asse
ss c
lient
s for
elig
ibili
ty fo
r oth
er a
nd re
late
d be
nefit
pro
gram
s.
I wan
t CG
S to
hel
p m
e to
app
ly fo
r oth
er b
enef
its, a
nd w
ill c
oope
rate
in c
ompl
etin
g as
sess
men
ts an
d in
pro
vidi
ng n
eede
d do
cum
enta
tion.
I wish
to re
ceiv
e th
e ne
wsle
tter,
STA
-Wel
l New
s, fro
m th
e Co
lora
do G
eron
tolo
gica
l Soc
iety
.
I h
ave
care
fully
read
, und
ersta
nd a
nd a
gree
to e
ach
of th
e ab
ove
optio
nal a
ckno
wle
dgem
ents
and
cons
ents.
S
IGN
ATU
RE:
D
ATE
:
Req
uire
d A
ckno
wle
dgem
ents
and
Con
sent
s
I u
nder
stand
that
if a
ppro
ved
for a
hea
ring
gran
t thr
ough
this
prog
ram
, I m
ust p
ay a
ny a
mou
nts n
ot c
over
ed b
y th
e gr
ant d
irect
ly to
my
hear
ing
aid
prov
ider
, and
I ag
ree
to d
o so
(do
not s
end
your
pay
men
t to
the
Colo
rado
Ger
onto
logi
cal S
ocie
ty, C
GS)
. The
pro
vide
has
agr
eed
to a
ccep
t thi
s gra
nt
as fu
ll or
par
tial p
aym
ent t
owar
ds th
e he
arin
g ai
ds a
nd m
olds
. CG
S do
es n
ot a
ccep
t any
resp
onsib
ility
for c
osts
abov
e th
e gr
ant a
war
d.
I u
nder
stand
that
the
gran
t pay
men
t fro
m th
e CG
S w
ill b
e m
ade
dire
ctly
to m
y he
arin
g ai
d pr
ovid
er. N
o pa
ymen
t will
be
mad
e to
me
and
CGS
will
no
t rei
mbu
rse
me
for w
ork
initi
ated
bef
ore
the
final
gra
nt a
war
d.
I u
nder
stand
that
the
prog
ram
and
gra
nt w
ill n
ot c
over
any
wor
k pe
rform
ed p
rior t
o m
y re
ceip
t of o
ffici
al le
tters
of g
rant
aw
ard.
I hav
e re
ceiv
ed a
cop
y of
and
hav
e re
ad th
e CG
S A
utho
rizat
ion
to D
isclo
se In
form
atio
n. I
auth
oriz
e m
y he
arin
g ai
d pr
ovid
er to
shar
e w
ith C
GS
and
with
oth
ers w
ho a
re a
par
t of t
his p
rogr
am, i
nfor
mat
ion
abou
t me
and
my
hear
ing
cond
ition
.
I und
ersta
nd th
at th
e CG
S do
es n
ot se
lect
a h
earin
g ai
d pr
ovid
er fo
r me
or a
ssig
n a
prov
ider
to m
e. I
may
sele
ct a
ny C
olor
ado
licen
sed
hear
ing
aid
prov
ider
. The
sele
cted
pro
vide
r mus
t agr
ee to
acc
ept t
he a
ppro
ved
gran
t aw
ard
for t
his p
rogr
am a
s ful
l or p
artia
l pay
men
t for
the
appr
oved
serv
ices
. Se
rvic
es n
ot c
over
ed b
y th
is pr
ogra
m m
ay b
e se
para
tely
neg
otia
ted
betw
een
mys
elf a
nd m
y he
arin
g ai
d pr
ovid
er.
I u
nder
stand
that
the
CGS
has a
“co
ordi
natio
n of
ben
efits
” po
licy.
I ag
ree
to c
oope
rate
in c
laim
ing
hear
ing
cove
rage
and
ben
efits
thro
ugh
Med
icai
d,
heal
th m
aint
enan
ce o
rgan
izat
ions
, priv
ate
insu
ranc
e, o
r any
oth
er b
enef
it or
pro
gram
to w
hich
I am
ent
itled
.
I cer
tify
that
all
info
rmat
ion
in th
is as
sess
men
t is c
ompl
ete,
true
and
cor
rect
and
that
I ha
ve n
ot le
ft ou
t or o
mitt
ed in
form
atio
n th
at m
ight
inac
cura
tely
re
pres
ent m
ysel
f or m
y ec
onom
ic a
nd so
cial
nee
d fo
r ass
istan
ce. I
und
ersta
nd th
at p
riorit
y is
give
n to
thos
e in
the
mos
t eco
nom
ic a
nd so
cial
nee
d.
I a
gree
to d
efen
d, in
dem
nify
and
hol
d th
e CG
S ha
rmle
ss fr
om a
ny a
nd a
ll cl
aim
s, di
sput
es, l
iabi
litie
s, or
cau
ses o
f act
ion
arisi
ng o
ut o
f the
agr
eem
ent
to p
rovi
de a
gra
nt o
r ass
istan
ce, o
r the
pro
vidi
ng o
f a g
rant
or a
ssist
ance
, or a
risin
g ou
t of s
ervi
ces a
nd g
oods
sold
or p
rovi
ded
to re
cipi
ents
of a
gra
nt
or a
ssist
ance
thro
ugh
CGS.
I h
ave
care
fully
read
, und
ersta
nd a
nd a
gree
to e
ach
of th
e ab
ove
ackn
owle
dgem
ents
and
cons
ents.
S
IGN
ATU
RE:
DA
TE:
Ret
urn
Ass
essm
ent F
orm
BY
MA
IL:
Col
orad
o G
eron
tolo
gica
l Soc
iety
, 133
0 Le
yden
St #
148,
Den
ver
CO
802
20
BY
FA
X:
303
-333
-911
2
QU
ESTI
ON
S: 3
03-3
33-3
482
You
r Nam
e:
Page 9 of 14
Colo
rado
Ger
onto
logic
al So
ciety
Hear
ing P
rovid
ers
10/2
7/20
17
Clin
ic Na
me
First
Nam
eLa
st N
ame
Addr
ess
City
ZipW
ork P
hone
Acce
nt o
n He
arin
gJo
anne
LaPo
rta, M
.A.,
CCC-
A11
89 S
Perry
St #
120
Cast
le R
ock
8010
4(3
03) 6
63-2
235
Adva
ntag
e Au
diol
ogy
Mel
issa
Fling
, AuD
3555
Luth
eran
Pkw
y #16
0W
heat
Rid
ge80
033
(303
) 255
-568
0
Adva
ntag
e Au
diol
ogy
Kier
aM
oore
, Aud
, CCC
-A35
55 Lu
ther
an P
kwy #
160
Whe
at R
idge
8003
3(3
03) 2
55-5
680
Adva
ntag
e Au
diol
ogy
Kim
berly
Albe
rt, M
A CC
C-A
400
W 1
44th
Ave
#25
0W
estm
inst
er80
023
(303
) 255
-568
0
Adva
ntag
e Au
diol
ogy
Kier
aM
oore
, Aud
, CCC
-A40
0 W
144
th A
ve #
250
Wes
tmin
ster
8002
3(3
03) 2
55-5
680
Adva
ntag
e Au
diol
ogy
Kim
berly
Albe
rt, M
A CC
C-A
7850
Van
ce D
r #22
5Ar
vada
8000
3(3
03) 2
55-5
680
Adva
ntag
e Au
diol
ogy
Kier
aM
oore
, Aud
, CCC
-A78
50 V
ance
Dr #
225
Arva
da80
003
(303
) 255
-568
0
Denv
er H
ealth
Aud
iolo
gy C
linic
777
Bann
ock S
t. M
S015
8De
nver
8020
4(3
03) 6
02-6
137
Belto
ne A
udio
logy
& H
earin
g Aid
s-Aur
ora
Dona
ldW
illiam
s, BC
-HIS
1220
3 E
Iliff A
ve, U
nit C
Auro
ra80
014
(303
) 696
-269
6
Belto
ne A
udio
logy
& H
earin
g Aid
s-Bro
omfie
ldSa
rah
Willi
ams,
AuD,
F-AA
A52
25 W
80t
h Av
e, St
e E
Arva
da80
003
(303
) 635
-222
2
Belto
ne A
udio
logy
& H
earin
g Aid
s-Lak
ewoo
dDa
vidIve
s, M
A, C
CC-A
, F-A
AA14
20 S
Wad
swor
th B
lvdLa
kew
ood
8023
2(3
03) 7
16-1
177
Belto
ne A
udio
logy
& H
earin
g Aid
s-Lak
ewoo
dM
ary J
oyce
Ulep
, AuD
, F-A
AA14
20 S
Wad
swor
th B
lvdLa
kew
ood
8023
2(3
03) 7
16-1
177
Belto
ne A
udio
logy
& H
earin
g Aid
s-Whe
at R
idge
Sara
hW
illiam
s, Au
D, F-
AAA
3352
You
ngfie
ld St
, Ste
BW
heat
Rid
ge80
033
(303
) 716
-117
7
Cent
er fo
r Bet
ter H
earin
gLy
ubov
Nem
anov
, AuD
4350
Wad
swor
th B
lvd, S
te 3
40W
heat
Rid
ge80
033
(303
) 736
-655
5
Colo
rado
Hea
ring S
pecia
lists
, Inc
Mich
ael
Iliff,
AuD
9397
Cro
wn
Cres
t Blvd
, Ste
307
Park
er80
138
(720
) 842
-189
0
Colo
rado
Hea
ring S
pecia
lists
, Inc
John
Mol
ina,
AuD
9397
Cro
wn
Cres
t Blvd
, Ste
307
Park
er80
138
(720
) 842
-189
0
Colu
mbi
ne H
earin
g Cen
ter
Mich
elle
Gros
s, CC
C-A
258
3rd
StFo
rt Lu
pton
8062
1(3
03) 8
57-6
688
Conn
ect H
earin
g, In
c.M
isty
Cres
po, H
IS49
80 K
iplin
g St,
#A5
Whe
at R
idge
8003
3(8
00) 6
75-5
485
Conn
ect H
earin
g, In
c.Lo
raSc
hwall
ie, A
uD49
80 K
iplin
g St,
#A5
Whe
at R
idge
8003
3(8
00) 6
75-5
485
Conn
ect H
earin
g, In
c.Di
ana
Com
bs, A
uD, C
CC-A
6702
W C
oal M
ine
Ave
Little
ton
8012
3(8
00) 6
75-5
485
Conn
ect H
earin
g, In
c.M
isty
Cres
po, H
IS67
02 W
Coa
l Min
e Av
eLit
tleto
n80
123
(800
) 675
-548
5
Conn
ect H
earin
g, In
c.Ka
thle
enGa
bler
, AuD
, CCC
-A95
0 E
Harv
ard
Ave,
#62
0De
nver
8021
0(8
00) 6
75-5
485
Conn
ect H
earin
g, In
c.La
rson
Stair
, HIS
950
E Ha
rvar
d Av
e, #
620
Denv
er80
210
(303
) 722
-088
6
Denv
er A
udio
logy
, LLC
Bunn
yBa
rber
, MS C
CC-A
90 M
adiso
n St
#10
7De
nver
8020
6(3
03) 8
32-2
054
Denv
er E
ar A
ssoc
iates
Stac
eyCo
hen,
AuD
, F-A
AA40
1 W
Ham
pden
Pl #
240
Engle
woo
d80
110
(303
) 788
-788
0
Denv
er E
ar A
ssoc
iates
Robe
rtFe
ehs,
M.D
.40
1 W
Ham
pden
Pl #
240
Engle
woo
d80
110
(303
) 788
-788
0
Denv
er E
ar A
ssoc
iates
Ashl
eyHu
erta
, AuD
, CCC
-A, F
-AAA
401
W H
ampd
en P
l #24
0En
glew
ood
8011
0(3
03) 7
88-7
880
Denv
er E
ar A
ssoc
iates
Robe
rtM
uckle
, M.D
.40
1 W
Ham
pden
Pl #
240
Engle
woo
d80
110
(303
) 788
-788
0
Denv
er E
ar A
ssoc
iates
Jenn
ifer
Torre
s, M
.A.,
CCC-
A, F-
AAA
401
W H
ampd
en P
l #24
0En
glew
ood
8011
0(3
03) 7
88-7
880
Denv
er E
ar A
ssoc
iates
Jenn
ifer
Wrig
ht, M
.A.,
CCC-
A, F-
AAA
401
W H
ampd
en P
l #24
0En
glew
ood
8011
0(3
03) 7
88-7
880
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Colo
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Ger
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logic
al So
ciety
Hear
ing P
rovid
ers
10/2
7/20
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Clin
ic Na
me
First
Nam
eLa
st N
ame
Addr
ess
City
ZipW
ork P
hone
Doug
las P
. Pel
ler,
DOKr
istin
eM
oore
, AuD
, CCC
-A, F
-AAA
9141
Gra
nt St
, Ste
240
Thor
nton
8022
9(3
03) 9
20-1
015
Echo
Hea
ring C
ente
rNa
than
Gilch
rist,
M.S
., F-
AAA
3501
S. C
oron
a St,
Ste.
2En
glew
ood
8011
2(3
03) 7
89-1
322
Fam
ily H
earin
g Cen
ters
- Bo
ulde
rH
Chris
toph
erSc
hwei
tzer
, PhD
, FAA
A30
59 W
alnu
t St
Boul
der
8030
1(3
03) 4
43-5
085
Fam
ily H
earin
g Cen
ters
- Br
oom
field
300
Nick
el St
#15
Broo
mfie
ld80
020
(303
) 465
-432
7
Fam
ily H
earin
g Cen
ters
- La
faye
tte27
70 A
rapa
hoe
Rd #
126
Lafa
yette
8002
3(3
03) 6
65-0
454
Gree
ley/
Brigh
ton
Hear
ing C
ente
rNa
than
Sand
ers,
BC-H
IS99
7 Pl
atte
Rive
r Blvd
, Ste
. EBr
ighto
n80
601
(303
) 659
-104
6
Harv
ard
Park
Hea
ring
Case
yAm
ann,
Au.
D., C
CC-A
, F-A
AA85
0 E
Harv
ard
Ave
#525
Denv
er80
210
(303
) 777
-432
7
Harv
ard
Park
Hea
ring
Laur
enGu
nn, A
uD, C
CC-A
, F-A
AA85
0 E
Harv
ard
Ave
#525
Denv
er80
210
(303
) 777
-432
7
Harv
ard
Park
Hea
ring
Eliss
aJo
don,
Au.
D., C
CC-A
850
E Ha
rvar
d Av
e #5
25De
nver
8021
0(3
03) 7
77-4
327
Harv
ard
Park
Hea
ring
Meg
han
Safk
o, M
A, F-
AAA
850
E Ha
rvar
d Av
e #5
25De
nver
8021
0(3
03) 7
77-4
327
Harv
ard
Park
Hea
ring
Laur
enGu
nn, A
uD, C
CC-A
, F-A
AA99
80 P
ark M
eado
ws D
r, St
e 20
0Lo
ne T
ree
8012
4(3
03) 7
99-8
778
Harv
ard
Park
Hea
ring
Meg
han
Safk
o, M
A, F-
AAA
9980
Par
k Mea
dow
s Dr,
Ste
200
Lone
Tre
e80
124
(303
) 799
-877
8
Hear
ing A
ssoc
iate
sBr
uce
Scha
chte
rle, A
u.D
1550
S. P
otom
ac St
, Ste
. 305
Auro
ra80
012
(303
) 369
-109
6
Hear
ing R
ehab
Cen
ter -
Arva
daCo
ryTi
ckle
, AuD
7850
Van
ce D
r. #1
95Ar
vada
8000
3(3
03) 4
32-3
601
Hear
ing R
ehab
Cen
ter -
Auro
raSc
ott
Dew
itt, A
uD13
99 S.
Hav
ana #
102
Auro
ra80
012
(303
) 337
-969
9
Hear
ing R
ehab
Cen
ter -
Cent
enni
al/E
ngle
woo
dJu
lieLin
k, Au
D68
51 S
Holly
Cir,
Ste
130
Cent
enni
al80
112
(303
) 221
-416
3
Hear
ing R
ehab
Cen
ter -
Denv
er/C
herry
Cre
ekNi
cole
Mille
r, Au
D15
5 S M
adiso
n St
, Ste
240
Denv
er80
209
(303
) 321
-140
2
Hear
ing R
ehab
Cen
ter -
Gold
enAn
gelin
aEs
pino
sa, A
uD28
01 Y
oung
field
St, U
nit 1
00Go
lden
8040
1(3
03) 2
31-9
118
Hear
ing R
ehab
Cen
ter -
Lake
woo
d So
uth
Drew
Price
, AuD
1088
1 W
Asb
ury A
ve, S
te 1
10La
kew
ood
8022
7(3
03) 9
85-4
423
Hear
ing R
ehab
Cen
ter -
Lake
woo
d So
uth
Cory
Tick
le, A
uD10
881
W A
sbur
y Ave
, Ste
110
Lake
woo
d80
227
(303
) 985
-442
3
Hear
ing R
ehab
Cen
ter -
Little
ton
Bran
diGr
eenh
ouse
, AuD
7325
S. P
ierc
e St
. #10
0Lit
tleto
n80
128
(303
) 933
-001
7
Hear
ing R
ehab
Cen
ter -
Little
ton
Broc
kSt
urlau
gson
, AuD
7325
S. P
ierc
e St
. #10
0Lit
tleto
n80
128
(303
) 933
-001
7
Hear
ing R
ehab
Cen
ter -
Lone
Tre
eBr
andi
Gree
nhou
se, A
uD98
94 R
osem
ont A
ve #
104
Lone
Tre
e80
124
(303
) 792
-992
2
Hear
ing R
ehab
Cen
ter -
Lone
Tre
eBr
ock
Stur
laugs
on, A
uD98
94 R
osem
ont A
ve #
104
Lone
Tre
e80
124
(303
) 792
-992
2
Hear
ing R
ehab
Cen
ter-
Park
erRe
becc
aDe
Witt
, AuD
1880
1 E
Mai
nstre
et #
185
Park
er80
134
(303
) 841
-697
0
Hear
ing R
ehab
Cen
ter -
Wes
tmin
ster
Anne
tteBe
rg, A
uD19
75 W
120
th A
ve, S
te 1
00W
estm
inst
er80
234
(303
) 255
-959
5
Hear
ing R
ehab
Cen
ter -
Wes
tmin
ster
Nico
leDe
wee
se. A
uD19
75 W
120
th A
ve, S
te 1
00W
estm
inst
er80
234
(303
) 255
-959
5
Kaise
r Per
man
ente
Hea
ring A
id C
ente
r10
240
Park
Mea
dow
s Dr.
Lone
Tre
e80
124
(303
) 338
-321
5
Kaise
r Per
man
ente
Hea
ring A
id C
ente
r20
45 Fr
ankli
n St
Denv
er80
205
(303
) 338
-321
5
Kaise
r Per
man
ente
Hea
ring A
id C
ente
r48
03 W
ard
Road
Whe
at R
idge
8003
3(3
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38-3
215
Page 11 of 14
Colo
rado
Ger
onto
logic
al So
ciety
Hear
ing P
rovid
ers
10/2
7/20
17
Clin
ic Na
me
First
Nam
eLa
st N
ame
Addr
ess
City
ZipW
ork P
hone
Lake
woo
d He
arin
g & Sp
eech
Cen
ter
Rand
all
Smith
, M.E
d., B
C-HI
S73
73 W
. Jef
fers
on A
ve, #
301
Lake
woo
d80
235
(303
) 988
-729
9
Mar
ion
Dow
ns C
ente
rSa
ndy
Gabb
ard,
PhD
4280
Hal
e Pa
rkw
ayDe
nver
8022
0(3
03) 3
22-1
871
Mar
ion
Dow
ns C
ente
rKr
ista
Iann
uzzi,
AuD
, CCC
-A42
80 H
ale
Park
way
Denv
er80
220
(303
) 322
-187
1
Mar
ion
Dow
ns C
ente
rJil
lW
ayne
, AuD
, CCC
-A42
80 H
ale
Pkw
yDe
nver
8022
0(3
03) 3
22-1
871
Mas
ter P
lan
Hear
ing A
id C
o.Ro
bert
Hoffa
rth, B
C-HI
S42
5 S.
Che
rry St
. #77
7De
nver
8024
6(3
03) 3
55-0
007
Mile
High
Oto
lary
ngol
ogy
Katie
Kern
s, Au
D38
95 U
pham
St #
201
Whe
at R
idge
8003
3(3
03) 4
87-0
834
Mou
ntai
n Pe
ak H
earin
g Ass
ocia
tes
Linda
Kise
r, M
A, C
CC-A
4045
Wad
swor
th B
lvd, #
110
Whe
at R
idge
8003
3(3
03) 4
25-3
344
Mou
ntai
n Pe
ak H
earin
g Ass
ocia
tes
Kayle
eKi
tten
Vela
, AuD
, CCC
-A40
45 W
adsw
orth
Blvd
, #11
0W
heat
Rid
ge80
033
(303
) 425
-334
4
New
Leaf
Hea
ring C
linic
Julie
Rane
y, M
.S.,
CCC-
A87
21 W
adsw
orth
Blvd
., St
e C
Arva
da80
003
(303
) 639
-532
3
Park
er &
Cas
tle R
ock C
ente
r for
Aud
iolo
gyLin
daBa
ker,
AuD
1121
1 S D
rans
feld
t Rd,
Ste
133
Park
er80
134
(303
) 841
-881
8
Peak
ENT
and
Voi
ce C
ente
rLin
dsay
Collin
s, Au
D40
3 Su
mm
it Bl
vd, S
te 2
04Br
oom
field
8002
1(7
20) 4
01-2
139
Prof
essio
nal H
earin
g Ser
vices
Inc.
Jeff
Balle
r, Au
D, B
CABA
2405
Wad
swor
th B
lvdLa
kew
ood
8021
4(3
03) 2
37-4
967
Rank
in C
linica
l Aud
iolo
gyKr
istin
Rank
in, M
.A.,
CCC-
A FA
AA46
00 H
ale
Park
way
#45
0De
nver
8022
0(3
03) 6
98-7
378
Scie
ntifi
c Hea
ring A
id C
o.Ja
mes
Simon
s, BC
-HIS
3439
S Lin
coln
StEn
glew
ood
8011
3(3
03) 7
77-9
720
Scie
ntifi
c Hea
ring A
id C
o.Ja
mes
Simon
s, BC
-HIS
7770
W 4
4th
Ave
Ste
1W
heat
Rid
ge80
033
(303
) 237
-940
0
The
Hear
ing C
linic
IraDe
chte
r, HI
S90
Mad
ison
St #
201
Denv
er80
206
(303
) 322
-005
4
The
Hear
ing C
linic
Robe
rtGa
rdne
r, Au
D90
Mad
ison
St #
201
Denv
er80
206
(303
) 322
-005
4
Unive
rsity
of C
olor
ado
Audi
olog
y Clin
ic16
35 A
uror
a Ct
, MS F
736
Auro
ra80
045
(720
) 848
-280
0
Page 12 of 14
Colorado Gerontological Society Senior Answers and Services Material Aid Division
Client Notification of Complaint Procedure Senior Answers and Services is committed to serving our clients to the best of our ability. Should you be dissatisfied with the Hearing or Vision Services you have received, the procedure for filing a complaint with the Colorado Gerontological Society is listed below. In accordance with the Older Americans Act (OAA) Sec, 307(5), Vol 10.910.1, and ASU Memorandum 04-27 consumer complaints may initially be verbal or written. 1. A complaint, in the context of Volume 10.900 rule, is an expression of dissatisfaction by:
a. An older individual receiving services under the Older Americans Act (OAA) or State Funded Programs for Seniors (SFPS), or his/her representative or caregiver;
b. An applicant is an older adult who has applied for services under the OAA or SFPS, or his/her representative or caregiver.
2. Older individuals receiving services, applicants for services, or their representatives or caregivers may file a complaint related to the following: a. Any action or failure to act which impacts the older individual’s experience with programs
and services funded by the OAA or SFPS; b. Dissatisfaction with services including issues related to quality and quantity of services; c. Dissatisfaction with service providers (applicants select their own service providers who are
not employees or agents of Senior Answers and Services); or, d. Other issues related to OAA or SFPS programs raised by the older individual or his/her
representative or caregiver 3. Applicant complaints must be filed within 30 calendar days of the unsatisfactory experience to
Colorado Gerontological Society. 4. If a verbal complaint is made in person, the agency staff or volunteer receiving the complaint
shall assist the older individual in recording the complaint on the agency form. a. The narrative of the complaint shall be read back to the older individual to ensure that the
individual’s complaint is accurately documented and the older individual shall be asked to sign the complaint. The staff member shall sign and date the document to verify this step.
b. The older individual shall not be required to sign the complaint if he/she refuses or is unable to sign.
c. Senior Answers and Services will accept and act on anonymous complaints at the sole discretion of the Executive Director.
5. Complaints received by phone, in person or in writing, shall be investigated and documented on the agency form by the agency staff.
6. Complaints shall be forwarded to the executive director for follow-up and disposition. Written notice of the resolution shall be sent to the complainant within 15 working days. This notice shall include: a. A summary of the concern or issue b. The results of the investigation into the complaint and the service provider’s resolution or
attempted resolution of the concern, and
Page 13 of 14
Colorado Gerontological Society Senior Answers and Services Material Aid Division
Client Notification of Complaint Procedure c. Notification to the complainant of his/her right to appeal the service provider’s decision if
he/she is dissatisfied with the resolution, and instructions for filing such an appeals. 7. Complaints that can not be resolved by the executive director may be appealed to the Material Aid
Advisory Committee for review and disposition. Upon request, the older individual and/or the individual filing the compliant on behalf of the older individual, will be given an opportunity to have an in-person hearing with the Material Aid Advisory Committee.
8. Appeals that cannot be resolved by the Materials Aid Advisory Committee may be referred to the Colorado Gerontological Society Board of Directors for review and disposition. Upon request, the older individual and/or the individual filing the compliant on behalf of the older individual, will be given an opportunity to have an in-person hearing with the Colorado Gerontological Society Board of Directors.
9. Appeals that cannot be resolved by the Colorado Gerontological Society Board of Directors may be referred to the Denver Regional Council of Governments (DRCOG). Appeals that are referred to DRCOG will comply with the DRCOG Client Grievance Procedure. a. Colorado Gerontological Society is a contractor of the Denver Regional Council of
Governments Area Agency on Aging (AAA). If the complainant has a grievance with Colorado Gerontological Society, a written complaint may be submitted within 30 days from the time the problem occurred to the Area Agency on Aging Director, 1290 Broadway, Suite 700, Denver, CO 80203
b. The AAA Director shall investigate the complaint and respond in writing within fifteen (15) business days of receiving the complaint.
c. The written response from the AAA director shall include: A summary of the complainants concerns or issues. The results of the investigation into the complaint and If applicable, Senior Answers and Services resolution/response to the complainant’s
concerns. 10. If the complainant is dissatisfied with the complaint resolution by the Denver Regional Council of
Governments, a written appeal may be filed with the State Unit on Aging Director within 10 calendar days of receipt of the decision. Appeals that cannot be resolved by the Denver Regional Council of Governments may be appealed to the State Unit on Aging for review and disposition. Appeals can be sent to Office of Community Access and Independence, Aging and Adult Services, 155 Sherman St, 10th Floor, Denver CO 80203 303-866-2800 (Main line); 303-866-2696 (fax); and 888-866-4243 (toll free). a. Appeals that are referred to the State Unit on Aging shall comply with Vol.10.910.2. b. The State Unit on Aging Director or designee shall complete a review of the complaint and
resolution to that complaint, including all pertinent documentation or new information that may be available.
c. The State Unit on Aging Director will provide a written response to the complainant within 30 business days of receipt of the appeal.
d. This written response by the State Unit on Aging shall include notification of the complainant’s rights to an Administrative Law Judge hearing as described at Section 10.960, if he/she is dissatisfied with the resolution of the appeal, and instructions for requesting such a hearing.
Get MONEY BACK (up to $892.oo) for property taxes, rent, or heat you paid. Apply for the
COLORADO PROPERTY/ RENT / HEAT CREDIT (“PTC”) REBATE ______________________________________________________________________________
If you: Resided in Colorado for the ENTIRE YEAR Are NOT claimed as a dependent on someone’s tax return Are lawfully present in the United States Have income equal to or less than:
2015 Single: $12,953.00
Married: $17,460.00
2016 Single: $13,234.00
Married: $17,839.00
AND Are 65 years or older -OR- Are a surviving spouse and 58 years old by December 31st -OR- Were disabled for an entire year
_____________________________________________________________________________ You have 2 YEARS to apply for the rebate AFTER the end of the calendar year.
Application Deadlines: 2015 - December 31, 2017 2016 - December 31, 2018
______________________________________________________________________________ Accepted Forms of Identification Include:
A Colorado driver’s license or I.D. card. *Other forms of I.D. may be ok if you do not have a Colorado license or I.D.*
______________________________________________________________________________ The address on your PTC application must match the address on your driver's license or Colorado I.D. card. If the addresses do not match, your rebate will be delayed.
*To update your address take a “Change of Address” (DR 2285) form to any Colorado Motor Vehicle Division Driver’s License Office*
______________________________________________________________________________ There is FREE help applying for the “PTC” Rebate:
Colorado Gerontological Society – (303) 333-3482 Colorado Department of Revenue - (303) 238-7378 Volunteer Income Tax Assistance (VITA) - (800) 906-9887 Dial 2-1-1 (free call) to find a tax site near you.
______________________________________________________________________________ For the application and more information, see www.TaxColorado.com ‘Click’ on File
and PTC Rebate
Page 14 of 14
