Save Our Seniors In-Take Form

Each senior or adult with a disability must submit the following documentation to receive supplemental monthly supplemental need boxes through the Save Our Seniors program.

You will need the following documentation:

Identification:

• Official government issued Photo ID 
  • Mo Healthnet/Medicaid Card 
  • Medicare Card

• Proof of income- For each adult (anyone over 18) in the home
  • Pay stubs- 1 month
  • Social Security benefit letter
  • Disability benefits letter
  • Unemployment statement
  • If you are unemployed you will need to sign a form to that effect. 

Client Documentation

lf no, please move on the address portion. 

How many people live in your house in the following groups: (please write the number in the box)

I certify that I am a member of the household listed above and, that on behalf of this household, I have applied for Circle of Care St Louis Save our Seniors supplemental need boxes. I certify that all information regarding my household is true to the best of my knowledge.

The undersigned client certifies that the information / answers provided above are complete and true. You further agree to the following:

(Please read carefully. Any questions you may have can be directed at a Save Our Senior staff member)

• You understand that this program is to be used as a supplement resource only and is meant to supplement other assistance or resources you may receive.
• Food is provided on a FIRST COME, FIRST SERVED basis and I relinquish Circle of Care St Louis of all liability of any nature whatsoever and accept the food AS IS" and at my own risk. 
• There is no guarantee to the amount or type of food or product given and there will be no substitutions made.
• You will not sell the food or non-food products or exchange / barter food or nonfood products for services.
• Inappropriate behavior such as profanity, verbal abuse of staff, or any other disruptive behavior is prohibited. Any such behavior may result in the suspension or termination of your privileges with the Save Our Seniors program. 

I optionally designate the following person as an authorized representative to pick up my supplemental need boxes. 

Circle of Care, St. Louis collaborates with other organizations throughout the Sr. Louis area to bring seniors and adults with disabilities served the greatest number of resources available. It is necessary to share client information from time to time to accomplish this task properly and we need your permission to do so. This information is never sold to marketers or others but is only used on your behalf.

Information to Be Released: All records and information concerning my care and services that I have received and will receive from the releasing organizations, including alcohol or drug abuse treatment records (if any exist).

For the Purpose of: (a) providing coordinated housing, medical, social, psychological and other services to me, (b) evaluating the outcomes related to service delivery, and (c) to improve coordination of services to assist individuals and (d) to identify barriers and service gaps that block the path out of homelessness, and to help prevent homelessness. In the event of the publication of the results of the program, my identity will be kept confidential, although information about my circumstances may be discussed.

Not a Condition for Treatment: I understand that my authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or services, payment for or coverage of services, or ability to obtain treatment.

Right to Revoke: This authorization is subject to revocation at any time except to the extent that the agencies which are to make the disclosures have already taken action in reliance on this authorization. If not previously revoked, this consent will terminate at the end of our assistance.

Potential Re-disclosure: I understand that information that I authorize to be disclosed may be re-disclosed and not subject to medical privacy regulations. However, federal confidentiality rules (42 CFR, part 2) prohibit recipients from making any further disclosure of alcohol and substance abuse records unless further disclosure is expressly permitted by written consent of the person to whom they pertain or if disclosure is otherwise permitted by 42 CFR, part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

I authorize Circle of Care, St. Louis to share information regarding emergency assistance resources, funded by grants, county, state and federal government, community assistance programs and private donations. These programs are designed to help stabilize seniors and adults with disabilities who are in crisis. This authorization is designed to permit organizations to share client information in order to collaborate on services and promote stability.