EOHHS
www.mass.gov/masshealth


Commonwealth of Massachusetts
EOHHS
www.mass.gov/mrc

MassHealth use only

Date application received:

          /           /           

Application for Home- and Community-Based Services Waivers for Persons with 
Acquired Brain Injury (ABI)

Non-Residential Habilitation Waiver

ABI Waiver Information    •    1-866-281-5602    •    ABIinfo@umassmed.edu


The Acquired Brain Injury Non-Residential Habilitation (ABI-N) Waiver is 
available through MassHealth for people who have experienced an acquired brain injury. The ABI-N Waiver does not include residential habilitation services. Participants will reside in their own or someone else’s home with waiver services.


Applicant name                                                              
                                    Telephone number
(           )
Date of birth
/               /
Social security number               Gender              MassHealth ID 
number
M         F

Facility name                                                               
                                                              Date of 
admission
/                /

Facility address


I am applying for the ABI-N Waiver.

Is there someone other than yourself that we should contact about your 
application?
(Please check one.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes    
  No

Contact name                                                                
            Contact telephone number
(           )
Relationship
Contact address


If there is someone other than yourself that we should contact about your 
application or that you would like to act on your behalf, you may choose an 
eligibility representative to help you with some or all of
the responsibilities for applying for or getting health benefits. You can 
do this by filling out a MassHealth Eligibility Representative Designation Form (ERD). To request an ERD form, call ABI Waiver Information at 1-866-281-5602.

By signing this application, I am stating that
• I currently am in and have been in a nursing facility or chronic disease 
or rehabilitation hospital for 90 days or longer;
• I have an acquired brain injury diagnosis; and
• I sustained my brain injury at age 22 or older.

Signature of Applicant or Eligibility Representative                        
        Date



Send your completed application to: UMass ABI Waiver Unit, 333 South 
Street, Shrewsbury, MA 01545. Staff at the UMass ABI Waiver Unit will contact you when they have received your application. They will process the application.






ABI-A-N (11/10)