AMPA Enrollment Packet

Block 1: Patient Identification

Block 2: Type of Information & Documentation to be Disclosed

Eligibility Related Information & Documentation (ERI&D)* includes Medical treatment, Mental Health treatment, Drug and/or Alcohol treatment, HIV/AIDS treatment, Financial records, Bills, Legal Records, Health Insurance Eligibility Determination and Plans, and Social Service records, notes, tests, orders, referrals, and communications provided to or requested by AMPA to determine eligibility and/or the provision of program related services.

Block 3: Persons Authorized to Disclose Assigned/Authorized Care Coordinator/Manager or AMPA staff member, director, or designated agent

Block 4:Persons Authorized to Receive

Assigned/Authorized Care Coordinator/Manager and/or AMPA staff member, director, designated agent; Participating or collaborating medical providers such as physicians, nurses, aids, technicians, administration, scheduling, billing or otherwise applicable; Participating or collaborating ancillary providers, DME and/or healthcare supply companies, home health, hospice or otherwise applicable; Participating or collaborating locations such as clinics, centers, offices, practices/groups, temporary sites, hospitals, hospital network related entities or otherwise applicable; Participating or collaborating supportive services such as Ballad Associated Care Managers and Community Health Workers, insurance companies, pharmacies, dispensaries, prescription assistance programs, medical device, material, or implant donation programs, or otherwise applicable; Participating or collaborating government agencies, social service organizations, and/or community resources such as DHS, Social Security, Unemployment, HUD, mental health/counseling, substance abuse treatment, food banks, clothing closets, job training, or otherwise applicable; Non-participating medical providers, ancillary providers, locations, supportive services, government agencies, social service organizations, and/or community resources when attempting to recruit providers or procure program- related services

Block 5: Purposes of Disclosure

To determine initial and on-going medical, financial, residential, specific and general eligibility for any of the AMPA and AHCN programs: Specialty Care Coordination, Patient Services, and/or Ballad Associated Care Management; to assess for the appropriateness of diagnostic, specialty, or other related medical requests in relation to available resources; to communicate with participating and/or non-participating providers to ensure comprehensive, case-managed care; to confirm compliance with AMPA Policies, Procedures, and the Patient Responsibility Agreement, medical treatment plans, payment arrangements, health insurance billing and use of services, or otherwise applicable; to apply for related services; to refer for related services; to schedule appointments or other related services; to provide authorization for services; to categorize and track applicable costs by self- pay/billed, reimbursement/insured, or charity/donation; to recruit related services; for reporting to funding sources

Block 6: Methods of Disclosure

Unless otherwise stipulated, AMPA will provide and receive disclosed information through face-to-face discussion, telephone contact, paper, fax, mail, or email.

Block 7: Emergency Contact Person(s)

Block 8: Expiration This authorization will expire upon file closure, program disenrollment or receipt of written revocation to this authorization from the Patient.

Block 9: Signature/Date

 

*I accept the terms of this Authorization. I have read this form (or have had this form read to me) and understand its contents. I am the patient listed or am authorized to act on behalf of the patient as the patient's personal representative.

*I understand that if the person or entity that receives the described records/information is not a health care provider or health plan covered by federal privacy regulations, the records/information may be redisclosed and no longer protected by those regulations.

*I also understand that I may revoke this authorization at any time by delivering a written revocation to Appalachian Mountain Project Access: P.O. Box 973, Johnson City, TN 37605. This will have no effect on information already shared or actions already taken by reliance on this form.

This project is funded under the agreement with the State of Tennessee's Department of Health and U.S. Department of Health and Human Services. Updated March 2024

1. CONSENT: The undersigned consents to apply for eligibility with the Project Access program. The patient hereby authorizes the disclosure to Project Access of any financial information including, but not limited to, income, debts, earnings, expenses, bills, creditors, liens, loans, financial aid awards, bank statements, interest, legal judgements, court orders or agreements to determine eligibility. The patient hereby agrees to hold Project Access, its employees, officers, and agents harmless from any claim, suit, action or demand of the patient, the patients' creditors, or any other person, which might rise out of this application process. The patient understands that Project Access shares certain pieces of information and certain information may be shared to aid in the coordination of medical or social services to determine eligibility for programs outside of, but related to, Project Access programs. The patients understands that while completing the eligibility process for AMPA, the patient is also being screened for additional programs such as Ballad Associated Care Management and Community Health Worker programs through the Appalachian Highlands Care Network ( ACHN), in which AMPA participates. Project Access agrees that the information contained in the patient's file will be confidential and used only for legitimate business purposes under the Fair Credit Reporting Act and for legitimate health disclosures under HIPAA and HITECH.

2. FULL DISCLOSURE: The client further agrees to reveal all known debts, income, assets, insurance coverage, or other pertinent information necessary for Project Access to determine eligibility. The client states that to the best of the patient's knowledge all information furnished to Project Access on the patient's behalf is accurate

ACKNOWLEDGEMENT

I acknowledge that I will be provided a copy of the Patient Responsibility Agreement and will be scheduled with a Care Coordinator who will further explain this document and provide an opportunity for me to ask any questions. I understand that if I do not abide by this Agreement, I may be removed from the Project Access Program. I have also received a copy of Project Access's NOTICE OF PRIVACY PRACTICES. 

This program is funded under and agreement with the State of Tennessee