Certification/Consent: By signing below, I certify that I meet all eligibility requirements: That I am a breast cancer patient, using this assistance to help with transportation for health/medical needs; that I live in Bryan, Chatham, Effingham, Liberty, or Long County; and that my household income is below the 80% regional median income. By signing, I herby authorize Keepers of the Flame® Foundation, a not-for-profit corporation, shall have the right to share any and all information provided in this application (including PHI) to their grant providers, hospital partners, and third-party service providers associated with this digital application platform (Jotform) in order to assess eligibility, provide assistance, process fund distributions on my behalf, and evaluate program effectiveness. I understand that in granting permission with my signature below, Keepers of the Flame® Foundation will be able to integrate form responses into their GoogleDrive and GoogleSheets in order to effectively run the program. I understand that these person(s)/organization(s) above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information provided on this application. I understand that this application includes ALL of the items listed above, and I consent for Keepers of the Flame® Foundation to use the information provided to act on my behalf. I further understand that the submission of this application does not guarantee assistance. I also authorize Keepers of the Flame® Foundation to share my impact story with United Way, so that it may be used to demonstrate our collective impact in eliminating transportation barriers and helping our community members thrive. Your stories are also necessary for sustaining the Women United fundraising effort, which supplies KotF with this Transportation grant. By sharing this story with Keepers of the Flame, you give approval for this story to be shared with United Way of the Coastal Empire for them to use on social media or other platforms without identifiable information. I hereby release and hold harmless Keepers of the Flame® Foundation from any HIPAA or other legal issues that may arise from providing such third parties with access to such PHI data associated with the application intake and program enrollment. I further acknowledge that my participation in this program is voluntary. I hereby release Keepers of the Flame® Foundation, its board of directors, officers, volunteers, and any other third parties involved in running the program from any and all claims, demands, actions, liabilities and damages whatsoever by me or any third party in connection with my participation.
HIPPA WAIVER: I give my permission for my provider’s office to disclose my health records with Keepers of the Flame for the purpose of program enrollment and receiving payments, and for program quality review. - - Keepers of the Flame will not review medical records or information shared with health professionals. The information gathered will be strictly used for payment purposes, and to evaluate the effectiveness of the program. Form of Disclosure: Electronic copy or access via a web-based portal Hard copy I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. This authorization to share my health information is valid from the date of the signature below until I decide to revoke this authorization. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: KEEPERS OF THE FLAME FOUNDATION INC 329 PURPLE PLUM DR RINCON, GA 31326 I understand that: In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. I understand that I do not need to give any further permission for the information detailed to be shared with Keepers of the Flame. I understand by signing this document, it is not a guarantee of payment. I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.