GIVING ALLIANCE OF MYAKKA CITY, INC.

PO Box 83

Myakka City, FL 34251

email:

REQUIREMENTS FOR ASSISTANCE

FOR

QUALIFIED APPLICANTS

“Giving Alliance of Myakka City, Inc. conducts programs that promote, uphold, and empower the general welfare of the community by providing access to human resources to those in need. Programs target Manatee County, FL residents living in Myakka City and nearby areas.”

Requirements to be completed:

  1. Copies of two proofs of residency of Myakka City, FL such as:
  2. Driver’s license or government ID – issued at least one year
  3. Monthly bill showing your Myakka City address
  4. Tax return showing your Myakka City address
  5. Voter’s registration card showing your Myakka City address
  1. Documentation of diagnosis from a medical professional
  1. Signed HIPPA release of information form
  1. Your latest bank/financial statement showing a financial need
  1. Copies of medical or other outstanding invoices you want assistance with
  1. Fill out Application for Assistance form
  1. Send all completed requirements to P.O. Box 83, Myakka City, FL 34251

GIVING ALLIANCE OF MYAKKA CITY, INC.

PO Box 83

Myakka City, FL 34251

email:

APPLICATION FOR ASSISTANCE

Applicant Name: ______Age______

Address: ______

City, State, Zip: ______Email: ______

Telephone: ______Mobile: ______

Social Security Number: ______Marital Status______

Number of Dependents ______Ages______

Please state the reason(s) for your request for assistance ______

______

______

Please attach the following documentation to your application

  1. Proof of Myakka City Residency – two forms of proof required:
  2. Driver’s license or government ID – issued at least one year - Required
  3. Utility bill or other monthly bill showing address
  4. Tax return with address
  5. Voter’s registration card Applicant Initials ____
  1. Signed Hippa authorization letter attached and diagnosis or letter from physician acknowledging diagnosis of illness or injury
  2. List of financial help requested. Please attach all outstanding invoices for which payment is being requested. (Please see attachment for list of qualifying payments.)
  3. Total Requested: $______(Maximum: $750-revised 7/2013)
  4. Latest bank/financial statements. Include any checking, savings, money market, CD, or other financial holdings statement.
  5. List other sources of assistance you have received in the last twelve months. ______
  6. Signature of affidavit below.

I, ______, do hereby acknowledge that I am having financial difficulties due to life-threatening illness, chronic illness, or major physical injuries due to an accident. As such, I am requesting assistance from Giving Alliance of Myakka City Inc., as included and listed with this application.

Signature ______Printed Name ______

Date ______

Witness Signature: ______Witness Name: ______

Witness Address: ______

A copy of the official registration and financial information may be obtained from the Division of Consumer Services by calling toll-free 800-435-7352 within the State. Registration does not imply endorsement, approval, or recommendation by the state.

Applicant Initials ____

AUTHORIZATION FOR THE RELEASE OF

PROTECTED HEALTH INFORMATION (PHI)

TO GIVING ALLIANCE OF MYAKKA CITY, INC.

This Authorization form is designed to meet the requirements of a valid authorization as specified by the Standards for Privacy of Individually Identifiable Health Information (the “Privacy Rule”) at 45 CFR §164.508 and Florida Statutes Chapter 456 under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191.

All items on this authorization must be completed in full or the request will not be honored.

I hereby authorize ______to release the protected health information (“PHI”) of:

Patient: ______
Date of Birth: ______Phone #: ______

Address: ______

______

The information is to be released to: GIVING ALLIANCE OF MYAKKA CITY INC.

PO BOX 83

MYAKKA CITY FL 34251

Phone #: 941-350-2079

Fax #: 941-322-2783

______

___ Discharge Summary_____ Imaging Reports _____ Allergy Records

___ History and Physical exam_____ Diagnostic cardiology Reports_____ Immunizations

___Consultation reports _____ Laboratory reports _____ Radiology Reports/Films

___ Pre/Post Operative Reports _____ Treatment or Tests_____ Progress Reports

Other: ______Entire Record

I do ____ I do not ______wish to have information about HIV/AIDS released under this authorization.

I do ____ I do not ______wish to have mental health records released under this authorization.

I do ____ I do not ______wish to have information about drug/alcohol abuse treatment released under this authorization.

If ______is in possession of records from another provider, I do ______I do not ______wish to have those records released under this authorization.

The purpose of such disclosure is:

______At my request (only patient may check)______Employment

______Healthcare______Legal

______Payment/Insurance______Other: ______

Unless otherwise revoked, this Authorization expires on/when ______.

If no date is indicated, this Authorization will expire twelve (12) months after date of my signing this form.

______

I understand:

  • This Authorization to release health information is voluntary.
  • My treatment, payment for it and/or eligibility for enrollment or benefits cannot be conditioned on my signing this Authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity’s obligation to pay a claim, or (4) to create health information to provide to a third party.
  • I am entitled to receive a copy of this Authorization.
  • I may inspect my protected health information without signing this Authorization.
  • This Authorization to release health information may be revoked by me at any time, except to the extent that action has been taken prior to receipt of revocation. To revoke this Authorization, I understand that I must notify Giving Alliance of Myakka City Inc. in writing.
  • I understand that once information covered by this Authorization has been disclosed, redisclosure of the information by the recipient is possible and the information may no longer be protected by the federal regulations referenced above but may be protected by Florida Law.

______

Patient or Personal Representative’s SignatureDate

If signature is other than patient, explain your authority to act for the patient:

______

______

______

______

Witness(if patient unable to sign)Date

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