AKA Including Maiden & Nicknames 2024

I Client Name authorize Care Directions Arizona School of Dentistry and Oral Health Chicanos Por La Causa Maricopa County Employee Benefits and Health Ebony House Maricopa Integrated Health System Maricopa County Office of Health Education Promotion Phoenix Indian Medical Center Southwest Center for HIV/AIDS Sun Life Terros Ryan White HIV/AIDS Program Grantees and/or Contractors all Ryan White Part B Grantees and/or Contractors SAAF/Delta Dental and ADAP to disclose my protected health information PHI and other information from my records to any Ryan White HIV/AIDS Program RWHAP Grantee or Contractor operating in the State of Arizona. The purpose of the disclosure is to permit RWHAP Grantees and/or Contractors to exchange my PHI or other information from my records to Ryan White Contractors and Grantees for the purposes of Continuity of care treatment payment and health care operations including eligibility demographic health insurance premium and copay payment emergency treatment and/or payments to Contractors or other statistical reporting information Mandated reporting including client-level data reporting Disclosures required by law Legal process and proceedings Oversight including quality assurance reviews and audits of Ryan White-funded services provided Disclosure to a Medical Examiner Disclosure of notifiable public health conditions and Inclusion in shared data systems for demographic eligibility and other statistical reporting If in the course of providing services to a client a RWHAP Grantee or Contractor identifies information that could be harmful to the client or the public the provider may report that information to the appropriate authorities. FOR OFFICE USE ONLY Application Type Applicant is applying for Date Received - Initial/New Birthday Renewal RWPA RWPB RWPC - / Logged In/ Date Reviewed / FOR PRE-APPROVED APPLICATIONS Pending Documents DX BVF Distributed Labs Form to be Sent Missing Documents Received RES BVF Other Sent / Date Complete/Pre-App Type E-Mail VM TC FF AHCCCS Determination Incomplete MPP/Lab Request Sent to on FOR INCOMPLETE APPLICATIONS Assigned Reviewer Pre-Approved Complete Client Advised of Status Add. Info Needed on Reminder Contact Date Birthday Re-Enrollment ADAP Dental To be Closed on Date Scanned v06012017 Date Entered in RWISE Page 1 of 5 RESIDENCY Please provide ONE of the following residency documents issued within the allowable timeframes. My enrollment may be terminated if I exhibit violent or threatening behavior to any Ryan White/ADAP Program representatives. Proof of Healthcare Coverage as applicable AHCCCS card or approval letter Medicare card Private health insurance card AHCCCS Denial dated within the calendar year REQUIRED only for clients with income 150 FPL Denial due to failure to submit documentation is not accepted. Enrollment in Federal Emergency Services FES is considered an AHCCCS denial. If living in Maricopa or Pinal county applicable denials will be generated through the Central Eligibility Office. To revoke this authorization I must submit a written request to the following agencies Central Eligibility Office Care Directions 1366 E. Thomas Road Suite 203 Phoenix AZ 85014 OR Arizona Department Health Services 150 N. 18th Ave. Suite 130 Phoenix AZ. 85007 By signing this Release of Information I release all Ryan White Grantees and Contractors their employees officers directors medical staff and agents from any legal responsibility or liability for the disclosure of information to the extent indicated and authorized in this Release. I also understand that Ryan White Grantees and Contractors will maintain the confidentiality of my disclosed PHI or other information and that they will use my PHI or other information only for the purposes listed above. If shipping address is provided below medications Rx ONLY will be shipped to that address. Rx Shipping Address if different than mailing Apt/Suite City Email Address OK to E-Mail Secondary Phone Primary Phone Type Home Cell Work Other OK to leave messages Yes No Alternative Contact Person Relationship Ryan White Case Manager Name Agency Doctor Name Clinic Name Phone Number Aware of Status Contact instead of client Fax Number SSN information is not used for eligibility determination. It is used to verify income AHCCCS eligibility and/or verify Medicare coverage.