Jiles Jewels Care Package Intake form

Jiles Jewels Care Package Intake Form

For Breast Cancer Warriors diagnosed within 24 months and in active treatment. Attention: Please do not submit this form until you have your physician referral or care manager letter. Kind Reminder: We do our best to support as many individuals as possible; however, funding is limited. Applications will be reviewed in the order received, and once all funds have been allocated, the grant cycle will close.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Date
FemaleMale
Email
example@example.com
Phone Number
Format: (000) 000-0000.
HIPAA Consent to Use and Review Health Information for Care Package Eligibility

I understand that as part of applying for a care package from Jiles Jewels Inc., I may be asked to submit medical documentation, such as a physician referral or other health-related records. I give my permission for Jiles Jewels Inc. to review this information to determine my eligibility for program services.

I understand that:

The information I provide will be used only to assess my eligibility for a care package.
Any medical documents submitted will be kept private and secure, and shared only with authorized personnel involved in the eligibility review process.
My health information will be protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I have the right to request and review Jiles Jewels Inc.’s privacy practices.
I may revoke this consent at any time in writing, except when action has already been taken based on my prior consent.
By signing below, I confirm that I have read and understand this consent, and I give permission for Jiles Jewels Inc. to use and review my health information solely for the purpose of determining my eligibility for a care package.
I agreeI do not agree
Are you in active treatment meaning under a physician's care within 24 months of your diagnosis or a stage 4 thriver? Select applicable answer.
Please upload your physician or caseworker’s letter indicating you are in active treatment for breast cancer and date diagnosed.

Cancelof
Terms and Conditions

Terms and Conditions for Submitting Patient Information to Jiles Jewels 1. Acceptance of Terms By submitting your information to Jiles Jewels, you acknowledge that you have read, understood, and agree to these Terms and Conditions. If you do not agree, please do not submit your information. 2. Eligibility To be eligible to receive a care package, you must:Be a patient diagnosed with breast cancer in the last 24 months and in active treatment. Provide accurate and truthful information. Consent to the collection, processing, and use of your information as outlined in these Terms. 3. Information Collection and Use By submitting your request, you authorize Jiles Jewels to collect and store your personal information, which may include but is not limited to: Full name, Contact details (email, phone number, mailing address), Medical condition details relevant to care package qualification. Your information will only be used to assess eligibility, provide support services, and communicate with you regarding your request. 4. Confidentiality and Privacy Jiles Jewels is committed to protecting your privacy. Your information will not be sold or shared with third parties without your consent, except as required by law or for the fulfillment of your request. 5. No Guarantee of Care Package Submitting a request does not guarantee receipt of a care package. Packages are subject to availability and the discretion of Jiles Jewels. 6. Accuracy of Information You are responsible for ensuring the accuracy of the information provided. Jiles Jewels is not responsible for any issues arising from incorrect or incomplete information. 7. Limitation of Liability Jiles Jewels is not liable for any direct, indirect, incidental, or consequential damages arising from the submission of your information or receipt (or non-receipt) of a care package. 8. Changes to Terms and Conditions Jiles Jewels reserves the right to modify these Terms at any time. Any updates will be posted on our website, and continued submission of information constitutes acceptance of the updated Terms. 9. Contact Information If you have any questions or concerns about these Terms, please contact us at: jilesjewels@gmail.com. By submitting your information, you acknowledge that you have read and agreed to these Terms and Conditions.
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Jiles Jewels Care Package Intake Form

Terms and Conditions