Page 1 of 12

Colorado Gerontological Society 3006 East Colfax Avenue, Denver CO 80206 · 303-333-3482 · 303-333-9112 · www.senioranwers.org

INSTRUCTIONS TO APPLY FOR A SENIOR ANSWERS AND SERVICES HEARING GRANT PLEASE 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, 3006 East Colfax Avenue, Denver CO 80206 (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. 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.

Page 2 of 12

Dat

e R

ecei

ved

by C

GS:

Page 3 of 12

20

16B

asic

Con

sum

er In

take

Form

U

pdat

ed F

ebru

ary

12, 2

016

Bas

ic C

lient

Info

rmat

ion:

D

ate

of A

sses

smen

t:

/

/

*Firs

t Nam

e:*L

ast N

ame:

Mid

dle

Initi

al:

*Dat

e of

Birt

h:

/

/

Age

:*G

ende

r:

M

ale

Fe

mal

eA

re y

ou a

vet

eran

?

Yes

N

oW

hat i

s you

r prim

ary

lang

uage

?*W

hat i

s you

r rac

e?*A

re y

ou H

ispa

nic

or L

atin

o?

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

elig

ible

for M

edic

aid?

Y

es

No

*D

o yo

u liv

e al

one?

Yes

N

oH

ow m

any

peop

le li

ve in

you

r hou

seho

ld?

Wha

t is y

our m

onth

ly in

com

e?W

hat i

s you

r mon

thly

hou

seho

ld in

com

e?*I

f you

live

alon

e, is

you

r ind

ivid

ual m

onth

ly in

com

e be

low

$9

90?

Yes

N

o*I

f you

hav

e a

spou

se o

r par

tner

, is y

our m

onth

ly h

ouse

hold

in

com

e be

low

$1,

335?

Yes

No

Do

you

use

any

assi

stiv

e de

vice

s?

Yes

N

oIf

so, w

hich

one

s? _

____

____

____

____

____

____

____

____

____

*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:*R

esid

entia

l City

or T

own:

Mai

ling

Stat

e, Z

ip C

ode:

*Res

iden

tial S

tate

, Zip

Cod

e:Em

ail A

ddre

ss:

*Cou

nty

of R

esid

ence

:*P

hone

Num

ber (

incl

udin

g ar

ea c

ode)

:Em

erge

ncy

cont

act n

ame:

Rel

atio

nshi

p:Ph

one

Num

ber:

How

did

you

hear

abo

ut o

ur se

rvic

es?

A

AA

Bro

chur

e

AA

A N

ewsl

ette

r

Cha

nnel

9 S

enio

r Sou

rce

(TV

)

Con

greg

ate

Mea

l Site

C

urre

nt C

lient

Frie

nd/R

elat

ive

Se

nior

Fai

r

Wal

k-In

W

eb S

ite

Oth

er__

____

____

____

____

____

____

____

____

____

____

____

____

_D

o yo

u w

ant t

o he

arab

out o

ther

serv

ices

?

Yes

N

oIf

yes

, how

can

we

cont

act y

ou?

M

ail

Em

ail

Phon

eW

hen

is th

e be

st ti

me

to c

onta

ct y

ou?

Plea

se te

ll us

wha

t ser

vice

s you

wou

ld li

ke to

rece

ive:

I hav

e be

en in

form

ed o

f the

pol

icie

s reg

ardi

ng v

olun

tary

con

trib

utio

ns, c

ompl

aint

pro

cedu

res a

nd a

ppea

l rig

hts.

I am

aw

are

that

in o

rder

to re

ceiv

e re

ques

ted

serv

ices

, it m

ay b

e ne

cess

ary

to sh

are

info

rmat

ion

with

oth

er d

epar

tmen

ts o

r ser

vice

pro

vide

r an

d I h

erew

ith g

ive

my

cons

ent t

o do

so.

(If f

illed

out

by

asse

ssor

or v

ia p

hone

, ple

ase

have

ass

esso

r che

ck h

ere

and

sign

bel

ow

).

Sign

atur

e___

____

____

____

____

____

____

____

____

____

____

____

____

_ D

ate_

____

____

____

____

__

Off

ice

use

only

: In

form

atio

n fil

led

out b

y __

____

____

____

____

____

_

D

ate_

____

____

____

____

__1

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

sho

ppin

g w

ithou

t hel

p.

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

___

____

____

____

____

____

____

_

Page 5 of 12

Hea

ring

Add

endu

mL

angu

age A

bilit

y (P

leas

e C

heck

All

That

App

ly)

I

have

diffi

culty

read

ing

Engl

ish,

and

requ

ire h

elp

to d

o so

.

I ha

ve d

ifficu

lty w

ritin

g En

glis

h

I do

not

spea

k en

ough

Eng

lish

to ta

lk to

som

eone

who

onl

y sp

eaks

Eng

lish

and

have

them

und

erst

and.

I

do n

ot u

nder

stan

d En

glis

h to

spea

k to

an

Engl

ish

spea

king

per

son

with

out t

he a

id o

f an

inte

rpre

ter.

Rac

e an

d/or

Eth

nici

ty (P

leas

e C

heck

All

That

App

ly)

A

mer

ican

Indi

an

Ala

ska

Nat

ive

B

lack

/ A

fric

an-A

mer

ican

N

ativ

e H

awai

ian

/ O

ther

Pac

ific

Isla

nder

W

hite

H

ispa

nic/

Latin

o

Asi

an

Coo

rdin

atio

n of

Ben

efits

(Ple

ase

Che

ck A

ll Be

nefit

s You

Cur

rent

ly R

ecei

ve)

S

uppl

emen

tal S

ecur

ity In

com

e (S

SI)

C

olor

ado

Old

Age

Pen

sion

(OA

P)

Sup

plem

enta

l Nut

ritio

n A

ssis

tanc

e Pr

ogra

m (S

NA

P / F

ood

Stam

ps)

L

ow In

com

e En

ergy

Ass

ista

nce

Prog

ram

(LEA

P)

Ren

t Sub

sidy

(Sec

tion

8 or

HU

D h

ousi

ng)

C

olor

ado

Prop

erty

Tax

/Ren

t/Hea

t Reb

ate

(PTC

104

)

Tem

pora

ry A

ssis

tanc

e fo

r Nee

dy F

amili

es (T

AN

F)

Tot

al L

ongt

erm

Car

e (T

LC)

A

Hea

lth M

aint

enan

ce O

rgan

izat

ion

(HM

O),

Priv

ate

Fee

for S

ervi

ce

(P

FFS)

or S

peci

al N

eeds

Pla

n (S

NP)

(Ple

ase

Indi

cate

Bel

ow):

_

____

____

____

____

____

____

____

____

____

____

____

____

____

___

M

edic

aid

M

edic

are

Savi

ngs P

rogr

ams (

MSP

)

Q

ualif

ied

Med

icar

e B

enef

it (Q

MB

)

Q

ualif

ying

Indi

vidu

al 1

(QI-

1)

S

peci

al L

ow-I

ncom

e M

edic

are

Ben

efit

(SLI

M-B

)

Hom

e an

d C

omm

unity

Bas

ed S

ervi

ces (

HC

BS)

V

eter

ans A

dmin

istra

tion

Ben

efits

(VA

Ben

efits

)

Hea

ring

Aid

Insu

ranc

e (P

leas

e In

dica

te B

elow

):

___

____

____

____

____

____

____

____

____

____

____

____

____

____

_

Oth

er H

earin

g B

enefi

t/Gra

nt (P

leas

e In

dica

te B

elow

):

___

____

____

____

____

____

____

____

____

____

____

____

____

____

_

Volu

ntar

y C

ontr

ibut

ions

This

pro

gram

is m

ade

poss

ible

thro

ugh

a gr

ant f

rom

the

Old

er A

mer

ican

s Act

, thr

ough

the

Den

ver R

egio

nal C

ounc

il of

Gov

ernm

ents

, Are

a Age

ncy

on A

ging

, oth

er g

rant

s and

priv

ate

dona

tions

.Any

per

son

rece

ivin

g se

rvic

es sh

all h

ave

the

oppo

rtuni

ty to

con

tribu

te to

war

ds th

e co

st o

f the

serv

ice.

N

o el

igib

le p

erso

n sh

all b

e de

nied

a se

rvic

e be

caus

e of

thei

r ina

bilit

y an

d/or

cho

ice

not t

o co

ntrib

ute.

Indi

vidu

als a

re n

ot c

harg

ed a

set f

ee b

y th

e C

olor

ado

Ger

onto

logi

cal S

ocie

ty fo

r any

serv

ice

prov

ided

. Ind

ivid

uals

are

wel

com

e to

mak

e a

volu

ntar

y do

natio

n to

hel

p ot

her s

enio

rs re

ceiv

e as

sist

ance

. Don

atio

ns fo

r gra

nts o

r oth

er p

roje

cts m

ay b

e se

nt to

Col

orad

o G

eron

tolo

gica

l Soc

iety

, 300

6 E

Col

fax

Ave,

Den

ver C

O 8

0206

.

Your

Nam

e:

Page 6 of 12

Hea

ring

Nee

ds

1.

I hav

e ha

d co

ntin

uing

diffi

culty

with

my

hear

ing

for m

ore

than

a y

ear.

2

. I h

ave

troub

le h

earin

g ve

ry lo

w o

r ver

y hi

gh p

itche

s.

3.

I hav

e di

fficu

lty h

earin

g m

id-r

ange

pitc

hes.

4

. I h

ave

a hi

stor

y of

ear

infe

ctio

ns.

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 can

not u

se th

e te

leph

one

with

out a

ssis

tanc

e.

7.

I hav

e ex

trem

e di

fficu

lty u

nder

stan

ding

wha

t peo

ple

are

sayi

ng w

hen

we

spea

k fa

ce to

face

.

8.

I avo

id so

cial

inte

ract

ions

/act

iviti

es b

ecau

se o

f my

diffi

culty

hea

ring.

9

. I d

o no

t hav

e a

hear

ing

aid,

or t

he o

ne(s

) I h

ave

is/a

re m

ore

than

five

yea

rs o

ld.

1

0. I

have

an

ongo

ing

heal

th p

robl

em th

at is

impa

ctin

g m

y ab

ility

to h

ear (

Plea

se li

st c

ondi

tion(

s) o

n lin

e be

low

)

___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

_W

hich

ear

is su

fferin

g fr

om h

earin

g lo

ss (i

f bot

h, c

heck

bot

h)?

R

ight

Ear

L

eft E

ar

Cho

ose A

Hea

ring

Aid

Pro

vide

r (A

udio

logi

st)

1. C

hoos

e a

hear

ing

aid

prov

ider

from

the

atta

ched

list

(or a

sk y

our p

erso

nal p

rovi

der i

f he/

she

will

acc

ept a

gra

nt fr

om o

ur p

rogr

am).

2. C

all t

he h

eari

ng a

id p

rovi

der t

o as

k if

they

will

take

you

as a

new

pat

ient

with

the

Seni

or A

nsw

ers a

nd S

ervi

ces H

eari

ng P

rogr

am.

Prov

ider

’s N

ame:

Clin

ic /

Offi

ce N

ame:

Add

ress

:C

ity, Z

IP C

ode

Phon

e:Fa

x:

Your

Nam

e:

Page 7 of 12

Your

Nam

e:

Aut

hori

zatio

n to

Dis

clos

e In

form

atio

n to

the

Col

orad

o G

eron

tolo

gica

l Soc

iety

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 IN

FOR

MAT

ION

WIL

L B

E D

ISC

LO

SED

?•

All

reco

rds a

nd o

ther

info

rmat

ion

rega

rdin

g he

arin

g as

sess

men

ts, r

ecom

men

ded

treat

men

ts, h

earin

g w

ork

perf

orm

ed a

s wel

l as n

ot p

erfo

rmed

or

dec

lined

, ref

erra

ls to

oth

er h

earin

g pr

ovid

ers,

and

com

plic

atin

g m

edic

al c

ondi

tions

or o

ther

impa

irmen

ts.

• In

form

atio

n ab

out h

ow m

y im

pairm

ents

affe

ct m

y ab

ility

to c

ompl

ete

the

auth

oriz

ed tr

eatm

ent p

lan.

WH

O M

AY D

ISC

LO

SE IN

FOR

MAT

ION

AB

OU

T M

E?

• A

ll he

arin

g an

d m

edic

al so

urce

s (au

diol

ogis

ts, h

eairn

g ai

d pr

ovid

ers,

hosp

itals

, clin

ics,

labs

, phy

sici

ans,

psyc

holo

gist

s, et

c.) i

nclu

ding

men

tal

heal

th, c

orre

ctio

nal,

addi

ctio

n tre

atm

ent,

and

VA 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 h

earin

g pr

ovid

ers

• Em

ploy

ers

• O

ther

s who

may

kno

w a

bout

my

cond

ition

(som

eone

hel

ping

me

fill o

ut th

is fo

rm, f

amily

, int

erpr

eter

s, fr

iend

s, ne

ighb

ors,

publ

ic o

ffici

als,

etc)

.TO

WH

OM

MAY

INFO

RM

ATIO

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, C

olor

ado

Dep

artm

ent o

f Hum

an S

ervi

ces o

ther

age

n-ci

es o

r org

aniz

atio

ns th

at fu

nd o

r fina

nce

this

pro

gram

, 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

-er

s, an

d ot

her m

edic

al p

rofe

ssio

nals

con

sulte

d. TH

E P

UR

POSE

OF

TH

IS A

UT

HO

RIZ

ATIO

N IS

• To

det

erm

ine

the

spec

ific

serv

ices

for w

hich

this

pro

ject

will

mak

e a

gran

t, an

d to

mon

itor t

he p

rovi

sion

of s

ervi

ces l

eadi

ng to

succ

essf

ul c

om-

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

ER

AL

PRO

VIS

ION

S•

This

aut

horiz

atio

n is

goo

d fo

r five

yea

rs fr

om th

e da

te si

gned

(nex

t to

my

sign

atur

e be

low

).•

I aut

horiz

e th

e us

e of

a p

hoto

copy

, fax

ed c

opy,

or o

ther

ele

ctro

nic

copy

of t

his f

orm

for t

he d

iscl

osur

e of

the

info

rmat

ion

desc

ribed

abo

ve.

• I m

ay w

rite

to th

e C

olor

ado

Ger

onto

logi

cal S

ocie

ty to

revo

ke th

is a

utho

rizat

ion

at a

ny ti

me.

• 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 h

ave

read

this

form

and

the

Col

orad

o G

eron

tolo

gica

l Soc

iety

’s p

rivac

y po

licy

or h

ad th

em e

xpla

ined

to m

e an

d ag

ree

to th

e di

sclo

sure

s.

Com

plet

e an

d si

gn b

elow

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:

/

/ A

ddre

ss:

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.

SIG

NAT

UR

E:

DAT

E:

Req

uest

for A

dditi

onal

Ser

vice

s•

I und

erst

and

that

CG

S no

rmal

ly a

ttem

pts t

o as

sess

clie

nts f

or e

ligib

ility

for o

ther

and

rela

ted

bene

fit p

rogr

ams.

• I w

ant C

GS

to h

elp

me

to a

pply

for o

ther

ben

efits

, and

will

coo

pera

te in

com

plet

ing

asse

ssm

ents

and

in p

rovi

ding

doc

umen

tatio

n.

• I w

ish

to re

ceiv

e th

e qu

arte

rly n

ewsl

ette

r, ST

A W

ell N

ews,

from

CG

S.I h

ave

care

fully

read

, und

erst

and

and

agre

e to

the

abov

e op

tiona

l ack

now

ledg

emen

ts a

nd c

onse

nts.

SIG

NAT

UR

E:

DAT

E:

Req

uire

d A

ckno

wle

dgem

ents

and

Con

sent

s•

I und

erst

and

that

if a

ppro

ved

for a

hea

ring

gran

t thr

ough

this

pro

gram

, 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

CG

S). T

he p

rovi

der h

as a

gree

d to

acc

ept t

his g

rant

as f

ull o

r par

tial p

aym

ent

tow

ards

the

hear

ing

aids

and

mol

ds. C

GS

does

not

acc

ept a

ny re

spon

sibi

lity

for c

osts

abo

ve th

e gr

ant a

war

d.

• I u

nder

stan

d th

at th

e gr

ant p

aym

ent f

rom

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

CG

S w

ill

not r

eim

burs

e m

e fo

r wor

k in

itiat

ed b

efor

e th

e fin

al g

rant

aw

ard.

• I u

nder

stan

d th

at th

e pr

ogra

m a

nd g

rant

will

not

cov

er a

ny w

ork

perf

orm

ed p

rior t

o m

y re

ceip

t of o

ffici

al le

tters

of g

rant

aw

ard.

• I h

ave

rece

ived

a c

opy

of a

nd h

ave

read

the

Col

orad

o G

eron

tolo

gica

l Soc

iety

’s A

utho

rizat

ion

to D

iscl

ose

Info

rmat

ion.

I au

thor

ize

my

hear

ing

aid

prov

ider

to sh

are

with

CG

S an

d w

ith o

ther

s who

are

a p

art o

f thi

s pro

gram

, inf

orm

atio

n ab

out m

e an

d m

y he

arin

g co

nditi

on.

• I u

nder

stan

d th

at C

GS

has a

“co

ordi

natio

n of

ben

efits

” po

licy.

I ag

ree

to u

se h

earin

g ai

d co

vera

ge a

nd b

enefi

ts th

roug

h he

alth

mai

nten

ance

org

a-ni

zatio

ns, p

rivat

e in

sura

nce,

or a

ny o

ther

hea

ring

bene

fit o

r pro

gram

whi

ch I

curr

ently

rece

ive.

• I c

ertif

y th

at a

ll in

form

atio

n in

this

ass

essm

ent i

s com

plet

e, tr

ue a

nd c

orre

ct a

nd th

at I

have

not

left

out o

r om

itted

info

rmat

ion

that

mig

ht in

ac-

cura

tely

repr

esen

t mys

elf o

r my

econ

omic

and

soci

al n

eed

for a

ssis

tanc

e. I

unde

rsta

nd th

at p

riorit

y is

giv

en to

thos

e in

the

mos

t eco

nom

ic a

nd

soci

al n

eed.

• I a

gree

to d

efen

d, in

dem

nify

and

hol

d th

e C

olor

ado

Ger

onto

logi

cal S

ocie

ty h

arm

less

from

any

and

all

clai

ms,

disp

utes

, lia

bilit

ies,

or c

ause

s of

act

ion

aris

ing

out o

f the

agr

eem

ent t

o pr

ovid

e a

gran

t or a

ssis

tanc

e, o

r the

pro

vidi

ng o

f a g

rant

or a

ssis

tanc

e, o

r aris

ing

out o

f ser

vice

s and

go

ods s

old

or p

rovi

ded

to re

cipi

ents

of a

gra

nt o

r ass

ista

nce

thro

ugh

the

Col

orad

o G

eron

tolo

gica

l Soc

iety

.I h

ave

care

fully

read

, und

erst

and

and

agre

e to

the

abov

e re

quire

d ac

know

ledg

emen

ts a

nd c

onse

nts.

SIG

NAT

UR

E:

DAT

E:

Ret

urn

Ass

essm

ent F

orm

By

Mai

l: C

olor

ado

Ger

onto

logi

cal S

ocie

ty, 3

006

E C

olfa

x Av

e, D

enve

r, C

O 8

0206

B

yFax

: 303

-333

-911

2 Q

uest

ions

/Com

men

ts: 3

03-3

33-3

482

Page 8 of 12

Your

Nam

e:

Page 9 of 12

Colorado

Geron

tologicalSoc

iety

HearingProv

iders

Augu

st8,2

015

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Williams,AuD

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Colorado

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Page 11 of 12

Colorado Gerontological SocietySenior Answers and Services Hearing and Vision Division

Client Notification of Complaint Procedure

The Colorado Gerontological Society is committed to serving our clients to the best of our ability. Should you be dissatisfied with the Hearing and 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

caregiver3. 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. Colorado Gerontological Sociey 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 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 appeal7. 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.

Page 12 of 12

8. Appeals that can not 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 can not 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, Colorado Gerontological Society resolution/response to the complainant’s concerns. 10. If the complainant is dissatisfied with the complaint resolution by teh 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 can not 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, 1575 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 will 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 $792.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

Ø Are lawfully present in the United States Ø Have income equal to or less than:

2014Single: $12,720.00

Married: $17,146.00

2015Single: $12,953.00

Married: $17,460.00

ANDØ Are 65 years or older -OR-Ø Are a surviving spouse and 58 years old by December 31st -OR- Ø Were disabled for an entire year

_______________________________________________________________________________

You have 2 YEARS to apply for the rebate AFTER the end of the calendar year. Application Deadlines:

2014 – December 31, 20162015 – December 31, 2017

_______________________________________________________________________________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• AARP Colorado - (888) 687-2277• 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