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
FirstN
ame
LastNam
eAd
dress
ClinicNam
eCity
Zip
WorkPh
one
Joan
neLaPo
rta,M
.A.,CC
C-A
1189
SPerrySt#
120
AccentonHe
aring
CastleRoc
k80
104(303
)663
-223
5Ca
mron
Meikle,AuD
,BCA
BA11
89SPerrySt#
120
AccentonHe
aring
CastleRoc
k80
104(303
)663
-223
5Do
nald
Williams,BC-HIS
1220
3EIliffAv
e,UnitC
Belto
neAud
iology&Hea
ringAids-Aurora
Aurora
8001
4(303
)696
-269
6Kirstie
Taylor,A
uD34
0E1stA
venu
e,Ste200
BBe
ltone
Aud
iology&Hea
ringAids-Broom
field
Broo
mfie
ld80
020(303
)635
-222
2Sarah
Williams,AuD
,F-AAA
340E1stA
venu
e,Ste200
BBe
ltone
Aud
iology&Hea
ringAids-Broom
field
Broo
mfie
ld80
020(303
)635
-222
2Da
vid
Ives,M
A,CCC
-A,F-AAA
5154
SBroad
way
Belto
neAud
iology&Hea
ringAids-Eng
lewoo
dEn
glew
ood
8011
3(303
)738
-999
9Da
vid
Ives,M
A,CCC
-A,F-AAA
1420
SW
adsw
orthBlvd
Belto
neAud
iology&Hea
ringAids-Lakew
ood
Lake
woo
d80
232(303
)716
-117
7Sarah
Williams,AuD
,F-AAA
1420
SW
adsw
orthBlvd
Belto
neAud
iology&Hea
ringAids-Lakew
ood
Lake
woo
d80
232(303
)716
-117
7Kirstie
Taylor,A
uD33
52You
ngfie
ldSt,SteB
Belto
neAud
iology&Hea
ringAids-W
heatRidge
Whe
atRidge
8003
3(303
)716
-117
7Micha
elIliff,AuD
9397
CrownCrestB
lvd,Ste307
Colorado
Hea
ringSp
ecialists,Inc
Parker
8013
8(720
)842
-189
0John
Molina,AuD
9397
CrownCrestB
lvd,Ste307
Colorado
Hea
ringSp
ecialists,Inc
Parker
8013
8(720
)842
-189
0Miche
lleGr
oss,CCC
-A25
83rdSt
Columbine
Hea
ringCe
nter
FortLup
ton
8062
1(303
)857
-668
8Bu
nny
Barber,M
SCC
C-A
90M
adiso
nSt#10
5De
nverAud
iology,LLC
Denv
er80
206(303
)832
-205
4Eliza
beth
Coug
hlan
,M.A.
401W.H
ampd
enPl.#2
40De
nverEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0Ro
bert
Feeh
s,M
.D.
401WHam
pden
Pl#
240
Denv
erEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0Trud
yFred
rics,M
.S.
401W.H
ampd
enPl#
240
Denv
erEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0As
hley
Huerta,A
uD40
1WHam
pden
Pl#
240
Denv
erEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0Jenn
ifer
Man
sana
res,M
.S.C
CC-A
401W.H
ampd
enPl.#2
40De
nverEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0Ro
bert
Muc
kle,M
.D.
401WHam
pden
Pl#
240
Denv
erEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0Jenn
ifer
Torres,M
.A.
401WHam
pden
Pl#
240
Denv
erEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0Jenn
ifer
Wrig
ht,M
.A.
401WHam
pden
Pl#
240
Denv
erEarAssoc
iates
Englew
ood
8011
0(303
)788
-788
0De
nverHea
lthAud
iologyClin
ic77
7Ba
nnoc
kSt.MS0
158
Denv
erHea
lthAud
iologyClin
icDe
nver
8020
4(303
)602
-613
7Krist
ine
Moo
re,A
uD,C
CC-A,F-AAA
9141
GrantSt,Ste24
0Do
uglasP
.Peller,DO
Thornton
8022
9(303
)920
-101
5Jode
neSp
encer,Au
.D,F-AAA
3501
S.C
oron
aSt,Ste.2
Echo
Hea
ringCe
nter
Englew
ood
8011
2(303
)789
-132
2HCh
ristoph
erSchw
eitzer,P
hD,FAA
A30
59W
alnu
tSt
FamilyHea
ringCe
nters-Bou
lder
Boulde
r80
301(303
)443
-508
5FamilyHea
ringCe
nters-Broom
field
300Nicke
lSt#
15FamilyHea
ringCe
nters-Broom
field
Broo
mfie
ld80
020(303
)465
-432
7FamilyHea
ringCe
nters-Lafayette
2770
Arapa
hoeRd
#12
6FamilyHea
ringCe
nters-Lafayette
Lafaye
tte
8002
3(303
)665
-045
4Natha
nGilchrist
,M.S.,F-AA
A85
0EHa
rvardAv
e#5
25Ha
rvardPa
rkHea
ring
Denv
er80
210(303
)777
-432
7Lauren
Gunn
,AuD
,CCC
-A,F-AAA
850EHa
rvardAv
e#5
25Ha
rvardPa
rkHea
ring
Denv
er80
210(303
)777
-432
7Lara
Strotheide
,AuD
,CCC
-A85
0EHa
rvardAv
e#5
25Ha
rvardPa
rkHea
ring
Denv
er80
210(303
)777
-432
7Natha
nGilchrist
,M.S.,F-AA
A92
18Kim
merDriv
e#2
00Ha
rvardPa
rkHea
ring
Lone
Tree
8012
4(303
)799
-877
8Lauren
Gunn
,AuD
,CCC
-A,F-AAA
9218
Kim
merDriv
e#2
00Ha
rvardPa
rkHea
ring
Lone
Tree
8012
4(303
)799
-877
8Lara
Strotheide
,AuD
,CCC
-A92
18Kim
merDriv
e#2
00Ha
rvardPa
rkHea
ring
Lone
Tree
8012
4(303
)799
-877
8Bruc
eScha
chterle
,Au.D
1550
S.P
otom
acSt,Ste.305
HearingAs
sociates
Aurora
8001
2(303
)369
-109
6Co
ryTickle,A
uD78
50Van
ceDr.#1
95He
aringRe
habCe
nter-A
rvad
aArvada
8000
3(303
)432
-360
1Ge
orge
Mod
reck,M
BA13
99S.H
avan
a#1
02He
aringRe
habCe
nter-A
urora
Aurora
8001
2(303
)337
-969
9
Page 10 of 12
Colorado
Geron
tologicalSoc
iety
HearingProv
iders
Augu
st8,2
015
FirstN
ame
LastNam
eAd
dress
ClinicNa
me
City
Zip
WorkPh
one
Julie
Link,AuD
6851
SHollyCir,Ste130
HearingRe
habCe
nter-C
entenn
ial/E
nglewoo
dCe
nten
nial
8011
2(303
)221
-416
3An
nette
Berg,A
uD15
5SMad
isonSt,Ste240
HearingRe
habCe
nter-D
enve
r/Ch
erryCreek
Denv
er80
209(303
)321
-140
2An
gelin
aEspino
sa,A
uD28
01You
ngfie
ldSt,Un
it10
0He
aringRe
habCe
nter-G
olde
nGo
lden
8040
1(303
)231
-911
8Ke
llyCo
rmier,Au
D10
881WAsburyAv
e,Ste110
HearingRe
habCe
nter-L
akew
oodSo
uth
Lake
woo
d80
227(303
)985
-442
3Bran
diGr
eenh
ouse,A
uD73
25S.P
ierceSt.#
100
HearingRe
habCe
nter-L
ittleton
Little
ton
8012
8(303
)933
-001
7Broc
kSturlaug
son,AuD
7325
S.P
ierceSt.#
100
HearingRe
habCe
nter-L
ittleton
Little
ton
8012
8(303
)933
-001
7Bran
diGr
eenh
ouse,A
uD98
94Rosem
ontA
ve#10
4He
aringRe
habCe
nter-L
oneTree
Lone
Tree
8012
4(303
)792
-992
2Broc
kSturlaug
son,AuD
9894
Rosem
ontA
ve#10
4He
aringRe
habCe
nter-L
oneTree
Lone
Tree
8012
4(303
)792
-992
2Nico
leDe
wee
se.A
uD19
75W
120
thAve
,Ste100
HearingRe
habCe
nter-W
estm
inster
Westm
inster
8023
4(303
)255
-959
5Stev
enWad
e,AuD
1880
1EMainstree
t#1
85He
aringRe
habCe
nter-P
arke
rPa
rker
8013
4(303
)841
-697
0Niya
Nolting
,HIS
6425
Wad
sworthBlvd,#11
0He
aringLife
ofA
rvad
aArvada
8000
3(303
)953
-597
6Tina
Man
cuso,A
uD11
150NHu
ronSt,Ste208
HearingLife
ofN
orthglen
nNo
rthg
lenn
8023
4(303
)426
-063
3Lo
neTree
Kaise
r10
240Pa
rkM
eado
wsD
r.Ka
iserP
erman
enteHea
ringAidCe
nter
Lone
Tree
8012
4(303
)338
-321
5SkylineClinic
Kaise
r20
45Frank
linSt
Kaise
rPerman
enteHea
ringAidCe
nter
Denv
er80
205(303
)338
-321
5Whe
atRidge
Kaise
r48
03W
ardRo
adKa
iserP
erman
enteHea
ringAidCe
nter
Whe
atRidge
8003
3(303
)338
-321
5Au
rora
Kaise
r14
701EExpo
sitionAv
eKa
iserP
erman
enteHea
ringAidClinic
Aurora
8001
2(303
)338
-321
5Lafaye
tteKa
iser
280Exem
plaCircle
Kaise
rPerman
enteHea
ringAidClinic
Lafaye
tte80
026(303
)338
-321
5Ce
nten
nial
Kaise
r55
55EArapa
hoeRd
Kaise
rPerman
enteHea
ringAidClinic
Centen
nial
8012
2(303
)338
-321
5Ra
ndall
Smith
,M.Ed.,B
C-HIS
3110
SW
adsw
orthBlvd,#10
7Lake
woo
dHe
aring&Spe
echCe
nter
Lake
woo
d80
227(303
)988
-729
9Sand
yGa
bbard,PhD
4280
HalePa
rkway
MarionDo
wnsCen
ter
Denv
er80
220(303
)322
-187
1Krist
aIann
uzzi,AuD
,CCC
-A42
80HalePa
rkway
MarionDo
wnsCen
ter
Denv
er80
220(303
)322
-187
1Jill
Wayne
,AuD
,CCC
-A42
80HalePk
wy
MarionDo
wnsCen
ter
Denv
er80
220(303
)322
-187
1Ro
bert
Hoffa
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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