Disclosure, I, the named above on page 1 understand that the iInformation provided on this application will be verified to ensure accuracy. Incorrect information will delay and/or prohibit financial assistance.
I, the named above on page 1, authorize JOIN HANDS MINISTRY to dislocse to and/or receive information pertaining to my current situation.
The Following information:
The purpose of the disclosure:
I understand that my records are protected under the federal regulations, 45CFR-health Insurance Portability and Accountability Act and cannot be disclosed without my written consent. I understand that I revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically on the date input on page 1.
I have read this form and/or had it explained to me and I understand its contents.
ALSO, For the health, safety, and comfort of all clients, visitors, staff and volunteers, we ask that patients and visitors follow the guidelines/expectations in our Code of Conduct. I, the named above on page 1 understand the Client and Visitor Code of Conduct for JOIN HANDS MINISTRY.
I agree to the following,
The Following Are PROHIBITED:
Clients and visitors who do not follow this Code of Conduct WILL BE ASKED TO LEAVE Join Hands Ministry property. If series circumstance, THE POLICE MAY BE CALLED. You may also be barred from Join Hands Ministry property indefinitely.