Membership Application

Membership Application

Any person in Minnesota who is living with HIV can sign up to use free Aliveness services.
The Aliveness Project requires proof of Minnesota Residency, Insurance, Income, and HIV Status to make you a member. It is very important you provide these proofs. The applicant is responsible for providing all documents.

If you complete the application and provide no proofs it may take significantly longer to process your membership.

Once you have submitted your application you will receive a response within 48 business hours about the status of your application and any further steps that may need to be taken.

Proof examples:

Verification of HIV in one of the following forms:

· Medical documentation listing your name, your date of birth, the ordering medical professionals name, the clinic, and diagnosis. (Ex. HIV labs from a clinic, signed drs note, completed Ryan White Healthcare Provider Request [DHS-3539D].)

Proof of MN Residence:

·         State ID or Driver’s License

·         Utility Bill or Benefits Statement with address listed

·         If homeless or recently moved to Minnesota you may request a Residency Verification form, which we will provide

Proof of Health Insurance:

·         Copy of health insurance card

·         Letter stating health insurance benefits or enrollment

· Policy and group numbers of insurance plan

Proof of Income:

· Pay Stub

· Benefits letter or other similar beneficiary letter

- If you are unemployed, retired, or otherwise not receiving income you may complete a No Income Statment, which we will provide.

This form is secure, confidential, and HIPAA compliant. It typically takes 30 minutes to complete.
Membership Requirements:

The Aliveness Project is a nonprofit organization with services provided by staff and volunteers. All services are free to members.

Requirements are that a person is living with HIV in the state of Minnesota (or additional select counties).

All people who use services provided by The Aliveness Project do so by choice and with the understanding that The Aliveness Project and its staff and volunteers assume no liability in conjunction with services and programs.

Members and guests are expected to adhere to the guidelines stated on the last page of this application. Membership and services provided are a privilege. We expect members and any guests to behave in an appropriate, respectful manner while at The Aliveness Project. Members who violate these guidelines are subject to suspension of their membership and certain services.

By completeing membership you acknowldege that there will be times the Aliveness Project may report or upload your information on your behalf to the Minnesota Department of Human Services. This is due to our state requirements and keeps services free and accessible to you. All information reported or uploaded in this way is kept strictly confidential. If you would prefer to compelete the paperwork yourself, for any reason, there is a section in the application that allows you to opt out, should you so choose.

Contact Information
Legal Name*

First NameMiddle InitialLast NameSuffix (Example: Sr, Jr, III )
Chosen / Preferred Name (if applicable)
Which name would you like us to use for communication:

Use my legal nameUse my chosen / preferred nameUse my chosen / preferred name at the Aliveness Project, but my legal name on mail and email
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Privacy/Permissions
Email - This is the primary method we will use to contact you and is the fastest option for hearing back about the status of your application.*
example@example.com
List your second contact preference in the case we are unable to reach you via email:*

Phone calls and Voice messagesMail
What Aliveness services interest you? Check all that apply.*

Food Shelf Groceries (Up to 60lbs of groceries once per month. Individuals using Food Shelf need to be enrolled the Ryan White Program, which keeps it free. If you are not enrolled we can refer you to our Ryan White specialist Andy Heisz to help make the process simple and easy!)To-Go Meals (Hot lunch and daily to-go meals.)Case Management (Help navigating insurance, housing, benefits, etc.) [CURRENTLY SCHEDULING 3-4 WEEKS OUT.]Medical Nutrition Therapy (Help with diet-related needs such as diabetes, high cholesterol, drug side effects, etc.)Medical Care Linkage (Help finding an HIV doctor - Our staff will connect you with HCMC-Hennepin County Medical Center.)Housing - Our Housing program is currently 100% full. We will update as soon as something changes.
Is there anything specific you need help with?

Household
Spouse/Partner (applicable if living with you)

First NameLast Name
Spouse/Partner Date of Birth

MonthDayYear
Spouse/Partner Gender
Is your spouse/partner an Aliveness member?

YesNo
Is your spouse/partner employed?

YesNo
If your spouse/partner is employed what is their yearly salary?
Number of dependent children living with you
Please complete the following for each dependent child in your household.
First Name   Last Name
Gender   Date of Birth

First Name   Last Name
Gender   Date of Birth
If you have additional children, please use this space to list their information:
I give permission for Aliveness to update information on my behalf to the Minnesota Department of Human Services to keep my access to services active across agencies and keep my eligibility up to date. If I say no I acknowledge it is my responsibility to complete and submit forms and applications to maintain my eligibility for services.*

YesNo
If you have selected "Yes," please provide your social security number so that we may use it update forms and documents to the Department of Human Services on your behalf. We keep this information strictly confidential and it will only be used for the purposes of communicating to DHS. If you do not have a social security number, or unable to access it, please indicate so below:
Emergency Contact*

First NameLast Name
Is your emergency contact aware of your HIV status?

YesNo
Relationship
What is your emergency contact's relation to you? Examples: friend, spouse/partner, mother, brother, etc.
Does your Emergency Contact need translation? If YES, in what language?
(Ex. "Yes, French." "Yes, Spanish." "No.")
Emergency Contact's Phone Number*

Case Manager/Physician Contact Information and ROI
In the event of hospitalization or passing, I would like The Aliveness Project to post a notice onsite so HIV community members can become aware and offer support to me or my loved ones.*

YesNo
How did you hear about The Aliveness Project?*
Release of Information (ROI)
for The Aliveness Project
Case Manager's Name (if you have one)

First NameLast Name
Case Manager's Agency/Organization
Case Manager's Phone Number
Case Manager's Email
example@example.com
Do you give The Aliveness Project permission to contact your case manager to request information (such as HIV verification, MN residency verification, or health insurance information) needed to process your membership?

YesNo
Physician or Provider's Name (this is the doctors we will contact for medical records)*

First NameLast Name
Clinic Name (this is the healthcare facility you would like us to contact for records)*
Clinic Phone Number
Clinic Fax Number
Please SIGN BELOW to allow us to connect with your provider: "I authorize my physician to verify or disclose information that confirms I am living with HIV (HIV positive) to The Aliveness Project in order to gain membership and access to services."*

Clear
Today's Date*

MonthDayYear

Verification of Eligibility for Membership
Membership Application

Release of Information

Verification of Eligibility for Membership
I, First Name* Last Name* , born on Date of Birth* authorize my health care provider, First Name* Last Name*, at Name of Clinic* to verify or disclose information that confirms I am living with HIV to The Aliveness Project.
Signature*

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MonthDayYear
Date
This verification form is valid for 90 days from the date of signature.
This section is to be completed by the Health Care Provider. Please print unless signature required.

This form is soley to establish eligibility of the applicant to become a member of, and to receive services provided by The Aliveness Project. According to the Bylaws of The Aliveness Project, the only requirement for membership is that an individual is living with HIV.

This information will be kept in confidential files along with the applicant's signed membership form. Thank you for your time!

I verify that ____________________________________ (Name of Applicant)

___________________ (Date of Birth) is living with HIV and is, therefore,

eligible to become a member of The Aliveness Project.

X___________________________________________ (Physician's Signature)

___________________ (Date)

Date of last medical appointment: ___________________

Date viral load/CD4 was verified: ___________________

Clinic/Agency: ____________________________________

Office Address: ______________________________________________

Phone: ____________________________________

Fax: ____________________________________

Please return form via fax (612) 822-9668 or mail (Director of Member Services, The Aliveness Project, 3808 Nicollet Avenue, Minneapolis, MN 55409). Thank you! Please call (612) 822-7946 with any questions.

Member Policies
HIPAA Policy/Client Confidentiality

The Aliveness Project will maintain your personal and demographic information in a confidential manner. Access to information about the services you receive will be limited to The Aliveness Project staff and to others for whom you have provided written consent to share or discuss your information. You will not be identified or identifiable in any written reports or publications without your written consent. Consent for The Aliveness Project staff to communicate with other staff is automatic if you choose to become a member at The Aliveness Project and staff will ensure those communications stay private.

By agreeing to participate in programs at The Aliveness Project, you agree to provide information at the time of enrollment and periodically thereafter that will assist in data collection, assessment, and funding for services. For these purposes, personally-identifiable information will be provided to the Minnesota Department of Health (MDH) in accordance with contract agreements; however, The Aliveness Project and MDH will maintain your confidentiality as outlined below at all times. The goal of this is to make it easier for you to access additional services. The Minnesota Department of Human Services (DHS) and Hennepin County Ryan White Program will receive aggregate or group data only. The HIV/AIDS Bureau of the U.S. Department of Health and Human Services Health Resource and Service Administration (HRSA) does receive encrypted client level data that does not identify you by name or include any other identifying personal information. The data collected and reported to our funders is used to identify the services that individuals living with HIV/AIDS need and use, identify barriers to those services and unmet needs, and evaluate future funding needs.

The Aliveness Project may also be required by state laws and regulations to release information about you in the following circumstances:
-If there is a subpoena or a court order mandating us to release your records for use in a court proceeding.
-If you are threatening to harm another person and you have stated both the identity of the person and the means by which you plan to harm that individual.
-If you are threatening to seriously harm yourself and have identified a means by which you plan to do so.
-If you are threatening to commit a serious crime or are suspected of committing a serious crime.
-If it is suspected that you are being maltreated by a caregiver or are not able to protect yourself from maltreatment.
-If there is a reason to believe you are abusing or neglecting a child or vulnerable adult.

New Hires & Case Management Clients

The Aliveness Project will follow the "Best Practices" when hiring personnel to be case managers or other service providers that work with confidential, data-sensitive information. Members who were or are currently case managed by an Aliveness medical case manager, worked with Outreach and Prevention, or a nutritionist cannot become employees of those programs prior to at least one year separation from those services or at the discretion of the Executive Director. Current members that are employees cannot be case managed or receive other services in a data-sensitive category at The Aliveness Project or have access to the Personal Medical Information of other clients. Anyone already in a dual-role position at the date of this policy was enacted (03/27/2014) will be exempt from this policy.

Client Bill of Rights

Any client/member of The Aliveness Project is entitled to the following rights:
The right to treatment with dignity and respect in a nonjudgmental manner, regardless of HIV status, race, ethnicity, age, sex, gender, sexual orientation, religion, country of origin, or physical/mental disability.

The right to keep one's HIV status and other personal information confidential, information will be withheld from all inquirers, including family members, spouse/partner, friends, medical providers, or law enforcement personnel except in cases of life-threatening situations, child abuse, or with the written request of the client.

The right to receive services whether or not a member is currently receiving medical care for HIV/AIDS.

The right not refuse or discontinue services at any time for any reason. This includes the right to inspect all client-specific documents, including intake forms, assessment forms, case notes, and other other documents pertaining to the client only.

The right to information pertaining to the grievance and appeals process in the event that a member has a dispute with a staff person or service provider of The Aliveness Project.

The right to be protected from sexual, verbal, and/or physical harassment from staff or other service providers.

The right to be protected from discharge from membership without due cause, notice and/or process.

The right to receive interpretation/translation services (for client with limited English proficiency or hearing impairment) if no staff speaks the client's language or the client has not arranged for an interpreter.

Non-discrimination Policy

It is the policy of The Aliveness Project that services will be provided to all individuals without discrimination on the basis of HIV status, race, ethnicity, religion, age, sex, gender, sexual orientation, religion, national origin, physical or mental disability, or any basis prohibited by law.

Grievance Policy

You have the right to file a grievance if you feel you have been treated unfairly in any way. You will suffer no repercussion in service delivery solely as a result of filing a grievance. All grievances will be addressed in a confidential manner.

If you have a grievance, you should first discuss it with the staff person with whom you are working. If this is not successful or if you feel that this is not an option, you should proceed with the following steps:
-A written statement may be prepared (including date and time of incident) of the grievance. If you prefer, a grievance may be communicated verbally.
-Submit the grievance to the staff person's supervisor. An appointment will be scheduled for you to meet with the supervisor to resolve your grievance. If the matter cannot be mediated, your grievance may be referred to the Executive Director for final resolution.

Grievances will receive prompt attention. Every effort will be made to address and resolve grievances within ten (10) business days. Written correspondences can be mailed or delivered to 3808 Nicollet Avenue, Minneapolis, MN 55409.

Client’s Consent for Services: I acknowledge that I have read and understand the above information and agree to receive services provided by The Aliveness Project under the conditions stated above. I may, without consequence, withdraw my participation from this organization’s services at any time. I may request and receive a copy of this signed consent form at any time. Any and all copies of this document are to be considered as binding as the original.
Aliveness Community Guidelines

The staff and volunteers of The Aliveness Project would like to welcome you; to insure your safety and enjoyment of programs and services, we have established several guidelines. These guidelines are required and expected of all members, volunteers, and staff.

The consumption, distribution, or disruptive behavior under the influence of alcohol or illegal substances while accessing services at The Aliveness Project, on building property, or at related off-site activities is prohibited.

Verbal abuse, sexual harassment, or physical threats directed towards staff, volunteers, or other members-under any circumstances-are not permitted. Racial or discriminatory slurs or insults are not allowed.

According to health code standards, only staff and authorized volunteers are permitted in the kitchen areas. Shoes and clothing must be worn throughout the building.

The removal of any items belonging to The Aliveness Project without explicit permission from staff is prohibited.

No animals of any kind are permitted in the dining room, with the exception of service animals.

Misrepresenting oneself as a member, volunteer, or staff of The Aliveness Project is prohibited.

Personal items may not be left or stored at The Aliveness Project. Unclaimed items will be placed on the "free table" after three days.

Program services are limited to use by members only.

It is expected that everyone (staff, volunteers, and members) will clean up after themselves after meals and other activities.

Sleeping is only permitted in lobby chairs and is not permitted at computers or in the dining room. No food consumption is allowed in the lobby.

Leave at close (4pm). Repeatedly leaving the building late will lead to a verbal warning. If the behavior continues it will lead to suspension from services.

You are responsible for your items. Keep a close eye on them.

Please smoke 30ft away from the building. This protects our members with asthma and other breathing conditions.

No porn use is allowed on Aliveness property. You will be asked to leave for the day. If you are viewing porn on the computers, you may have your computer privileges suspended.

No weapons on Aliveness property. Pointing weapons at others or threatening others with weapons will lead to a suspension from services.

Filming others, taking photos of others without permission, and live video calls are not allowed to protect everyones privacy. You will be asked to stop. Regular calls are just fine.

No solicitations. Ask the front desk staff to help put pamphlets and flyers on the bulletin boards.

If you are having difficulties with another member seek help from staff. Fights, aggressive yelling, hitting or kicking other members, the building, or furniture is not tolerated. You will be asked to leave for the day and may be suspended from services.

When accessing services, members are expected to comply with all program rules that may apply.

Breaching confidentiality by revealing the HIV status of a member or person seen at The Aliveness Project is prohibited.

Removal of Membership: Suspensions of more than thirty days may be deemed grounds for permanent suspension. Permanent suspension requires a two-thirds vote of the current Membership Advisory Committee (MAC). After receiving a permanent suspension, a person may reapply to the MAC for membership after one year. A two-thirds vote from the MAC will be required to regain membership.

If any of these behaviors occur over and over again it may result in longer or more severe suspensions from services.

Members are responsible for staying up to date of policies and the rules within the Aliveness space. If you would like to check updates please review our website, ask the front desk, or check-in with Member Eligibility and Records.
Please SIGN BELOW: -I confirm that I am applying for membership at The Aliveness Project and am eligible to become a member. -I have completed the application to the best of my abilities and will reach out if I need more information or assistance. - I acknowledge that I have read and understand the above information and agree to receive services provided by The Aliveness Project under the conditions stated above. - I may, without consequence, withdraw my participation (in writing) from this organization's services at any time and cancel the authorization of this release. I may request and receive a copy of this signed consent form and/or my membership application at any time. - Any and all copies of this document are to be considered as biding as the original. - The Aliveness Project cannot prevent re-disclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release the Aliveness Project from any and all liability resulting from a re-disclosure by the recipient. - This authorization last for one year after the date you sign it unless you specify a different date during the application process. -I have read and understood the Membership Requirements, Policies, Guidelines, Aliveness Code of Conduct and agree to abide by the guidelines once I become a member. I have read and understood this form and authorize release of the information described above. "*

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