Healthcare HIV AIDS Programme Request

Healthcare HIV AIDS Programme Request

This form requests enrollment and access to services provided by the HIV/AIDS programme. Completion of this form authorizes the programme to collect and use health information necessary for clinical care, case management, and service coordination in accordance with applicable privacy protections. Participation is voluntary and may be withdrawn at any time by written notice.

1. Patient Information

Patient Name:

Male    Female    Other    Specify:

2. Emergency Contact

3. Insurance / Payment

4. Clinical & Medical History

Pregnant: Yes No Unknown   If pregnant, Estimated Due Date:

Current or Past Substance Use: Yes No

5. Services Requested

Indicate the services for which the patient requests enrollment (check all that apply):

Medical care and antiretroviral therapy
Case management / care coordination
Adherence counselling and support
Partner notification / contact tracing support
Psychosocial support / counseling
Prevention services (condoms, PrEP referral for partners)
Home visits / community outreach
Social support (housing, food assistance)
Peer support groups
Referral to community services
Laboratory services and monitoring
Pharmacy coordination / medication pickup
Transport assistance
Financial assistance / support funds
Other:

6. Authorization to Share Health Information

I authorize the release and sharing of my HIV-related health information as necessary for the delivery of services requested above, including but not limited to clinical records, laboratory results, medication and adherence information, and care coordination data. Information may be shared among programme staff, contracted providers, laboratories, pharmacies, and social support agencies strictly for treatment, payment, and care coordination purposes.

Recipient Organization / Individual Name:

Scope of Disclosure (check all that apply):
All HIV-related records
Laboratory results only
Treatment summary and medication list
Enrollment verification and service plans
Purpose of Disclosure:

I understand that this authorization is voluntary. I may revoke it at any time by submitting a written revocation to the programme, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

7. Privacy, Confidentiality & Limitations

The programme maintains strict confidentiality of HIV-related information in accordance with applicable law. Exceptions to confidentiality include mandatory reporting requirements, court order, suspicion of abuse of a minor or vulnerable adult, or other legal obligations. Information may also be disclosed when necessary to prevent a serious and imminent threat to health or safety in accordance with law.

By signing below, I attest that the information provided on this form is true and accurate to the best of my knowledge, and I consent to enrolment in the HIV/AIDS programme and to the release and use of my health information as described above for purposes of treatment, care coordination, and support services.

I acknowledge that I have received or been offered a copy of the programme's privacy practices and that I understand my rights, including the right to withdraw consent and request restrictions on certain uses and disclosures, subject to programme policies and applicable law.

I acknowledge receipt of the programme privacy practices and understand my rights.

Sign Now