Eligibility Assessment Determination

Eligibility Assessment Determination

Serenity, Inc.
Introduction to the Eligibility Assessment Determination Form

Welcome to the Eligibility Assessment Determination form for Serenity, Inc. This form is designed to help us assess your eligibility for our services and programs. By providing accurate and complete information, you enable us to better understand your needs and determine the appropriate support and resources available to you.

The form is divided into several sections, each focusing on different aspects of your personal, medical, and financial information. These sections include:
- Personal Information: Collects your basic details such as name, contact information, and address.
- Housing Status: Gathers information about your current living situation.
- Veteran and Marital Status: Asks about your veteran status and marital status.
- Medical Contact Information: Requires details about your primary HIV care provider and case manager.
- Demographics: Collects demographic information including gender, ethnicity, and language preferences.
- Household and Income: Gathers information about your household members and income.
- Eligibility Criteria: Requires documentation to verify your eligibility.
- Benefits and Insurance: Asks about your insurance coverage and benefits.
- Medical Information: Collects information about your HIV status and treatment.
- HIPAA Policy: The Health Insurance Portability and Accountability Act (HIPAA) of 1996 establishes federal standards to protect sensitive health information.
- Submission Details: Provides your name and email for submission purposes.
Please ensure that all information provided is accurate and up-to-date. If you have any questions or need assistance while completing the form, do not hesitate to reach out to our support team. Your cooperation is greatly appreciated and will help us provide you with the best possible care and support. Thank you for taking the time to complete this form.

Personal Information

This section collects your basic personal details, including your full legal name, any other names you've used, phone number, email address, and residential address.
Legal First, Middle, and Last Name:*

First NameMiddle NameLast NameSuffix
Other Names Used:

First NameMiddle NameLast NameSuffix
Primary Phone Number:*
Please enter a valid phone number.
Primary Email:*
example@example.com
Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ok to send mail:*

YesNo
Mailing Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ok to send mail:

YesNo

Housing Status

This section asks about your current housing situation, such as whether you rent, own, or have another type of housing arrangement.
Housing Status:*
Permanent Housing Type: *
Veteran and Marital Status

Here, you indicate whether you are a veteran and provide your current marital status.
Veteran:*

YesNo
Marital Status:*

Medical Contact Information

This section gathers information about your primary HIV care provider, including the clinic or facility name, your physician's name and contact details, and your HIV case manager's information.
Primary HIV Care Clinic/Facility/Practice:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Providing HIV Care:

First NameLast Name
Phone Number:
Please enter a valid phone number.
HIV Case Management Agency:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HIV Case Manager:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Authorize Representative:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Other Subrecipient:

First NameLast Name
Phone Number:
Please enter a valid phone number.

Eligibility Criteria

This section requires you to provide documentation to verify your eligibility, such as proof of residency and income.
Acceptable Documents: To view the list of acceptable documents, click here.
HIV+ Diagnosis: [File Upload] (Required)*

Proof of HIV Status: Medical records indicating HIV diagnosis, Letter from healthcare provider confirming HIV status, HIV test results.
Cancelof
Documentation: *
Select the type of verification document.
Proof of Residency in Virginia: [File Upload] (Required)*

Proof of Residency: Utility bill (e.g., electricity, water, gas), Lease or rental agreement, Mortgage statement, Government-issued ID with address, Voter registration card, Letter from Lease Holding Roommate, Public Assistance Document, Government Correspondence, Vehicle Title, Student ID.
Cancelof
Tier 1 Documentation: *
Select the type of verification document.
Tier 2 Documentation:
Select the type of verification document.
Insurance Status: [File Upload] (Required)*

Proof of Insurance: Insurance card (Medicare, Medicaid, private insurance), Insurance policy documents, Letter from insurance provider.
Cancelof
Documentation:*
Select the type of verification document.
Proof of Low-Income Status: [File Upload] (Required)*

Proof of Income: Recent pay stubs, Tax returns (most recent year), Social Security benefit statement, Unemployment benefits statement, Letter from employer verifying income.
Cancelof
Documentation:*
Select the type of verification document.
Proof of No Income: [File Upload]

Proof of No Income: No Income Declaration Letter, Unemployment Benefits Statement, Zero Income Affidavit, Letter from a Social Worker or Case Manager, Proof of Application for Assistance.
Cancelof
Documentation
Select the type of verification document.

HIPAA Policy

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 establishes federal standards to protect sensitive health information.
- Purpose: This policy outlines the requirements for compliance with the Health Insurance Portability and Accountability Act (HIPAA) to protect patient privacy and confidentiality within Serenity Health Services.
- Client Rights: Clients are entitled to:
  - Access their medical records.
  - Limit the sharing of their information with other agencies, including funders.
  - Review their medical records for accuracy and request amendments.
- Disclosure Without Authorization: Health information may be disclosed without client authorization for certain national priority purposes, such as research or public health disease outbreaks.
- Grievance Process: Clients who believe their HIPAA rights have been violated may file a grievance with Serenity Health Services, the Virginia Department of Health, or the United States Department of Health and Human Services' Office for Civil Rights. Violations may result in fines and/or incarceration.
- Confidentiality and Security
  - Staff must maintain client confidentiality and secure client files, both paper and electronic.
  - Unauthorized disclosure of client information is prohibited.
- Authorization for Sharing Information
  - Personal Health Information (PHI) and Personal Identification Information (PII) may not be shared without prior written approval from the client.
  - A completed and signed release of information form must be on file before sharing any PHI or PII.
- Communication Protocols
  - All forms of communication, including telephone calls, faxes, correspondence, texting, telehealth, and emails, must be secure and HIPAA compliant.
  - Only unique identifiers, such as HMIS or REDCap numbers, may be used if authorized by a release of information form.
- File Management
  - Only files actively in use may be removed from the file cabinet.
    A File Pull Track Record form must be completed and left in place of the removed file.
  - Client file covers and tabs should only display unique identifiers, not names or initials.
- Office Protocols
  - Client records must be secured and out of sight when not in use, preferably in a locked drawer.
  - All files must be returned to locked file cabinets at the end of the day, with the File Pull Track Record completed.
- Data Entry
  - Ensure accuracy and completeness when entering data into HMIS, REDCap, or other authorized systems.
  - Log out of systems when leaving the office, even temporarily.
  - Prevent visitors from viewing information on screens and turn over client files to prevent unauthorized reading.
- Faxing and Copying
  - Verify that recipients are authorized before faxing or copying documents.
    Return original documents to the file immediately after faxing or copying.
  - If client data is found at the copier, return it to the appropriate staff member or place it in a sealed envelope under their door if they are not present.
- File Removal
  - Client files may not be taken out of the office without written permission from the executive director.
  - The executive director will maintain a log of files removed, reasons, and dates.
  - Files must be returned to the locked file cabinet within 24 hours unless an extension is requested and documented.
- Visitor Restrictions
  - No one may accompany a client to their appointment without a signed Release of Information form submitted 24 hours prior to the appointment.
  - Client PHI and PII must not be discussed with unauthorized persons, including staff, other providers, clients, family, or friends.
- Consultation for Uncertainty
  - Staff must consult with the executive director if unsure about any HIPAA regulations related to client-focused actions.

Submission Details

In this final section, you provide your name and email address for submission purposes.
Disclaimer

By signing and submitting this form, I hereby certify that all the information provided is true, accurate, and complete to the best of my knowledge. I understand that any false statements or misrepresentations may result in disqualification from the program and potential legal consequences. I agree to provide any additional documentation or information as required to verify the details provided in this form.

Next Steps

After you submit this form, our team will review the information provided to assess your eligibility for our services and programs. Once the review is complete, a case manager will reach out to you to inform you of your eligibility status. They will also provide you with any additional information or next steps required to proceed with your application. Thank you for your cooperation and patience during this process.
Date*

MonthDayYear
Applicant Legal Name:*

First NameLast Name
Applicant Email:*
example@example.com
Signature:*

Powered by Jotform SignClear
By providing your electronic signature on this form, you acknowledge and agree that it is legally binding and has the same validity and effect as a handwritten signature. Your electronic signature confirms that all information provided is true and accurate to the best of your knowledge.
Should be Empty:

Eligibility Assessment Determination

Personal Information

Housing Status

Veteran and Marital Status

Medical Contact Information

Demographics

Household and Income

Eligibility Criteria

Benefits and Insurance

Medical Information

HIPAA Policy

Submission Details