Table of Context

*1.) How to contact

Handi CapablewInc.

*2.) Questionnaire?

*3.) EQUIPMENT LOAN and gifts

*4.) The Statement Of Non- Discrimination

*5.) Definition Of Handicapped

*6.) HIPPA Statement

*7.) Read How We Have Helped Other

*8.) Statement Of Purpose

9.)  Prayer Request

*10.) Authorization to  Release Protected Health Information

 
 
 

 

 

 

 

 

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Text Box: *5.) Definition of Handicapped Handicap exists when individuals with impairment or disability are unable to fulfill one or more of the Major roles that are considered normal for their age, gender, and culture. Special consideration will be given to applicants with disabilities with a view to accommodating their needs which lead them to employment, to encourage adults to be tax payers. Our ability to help is based on our funds and we only help persons with disabilities in accordance with our Articles Of Incorporation And By- Laws.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*10.) Authorization to Release Protected HealthI nformation

 

This is the Authorization for Handi CapablewInc.

to use your information for the purpose of helping you.

This is only needed if I tell you that it is necessary.

 

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7.) Sign this form and ask your Dr to sign it –

8.) Mail the form to         Handi CapablewInc.

2450 Louisiana St. Ste 400-350        Houston, TX 77006

 
 
Text Box: 8.) Authorization to Release Protected Health Information Handi CapablewInc. 2450 Louisiana St. Ste 400-350 Houston, TX 77006 AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION Patient/Clients Name: __________________________________________________ DOB: ____________________I, Patient or Legal Representative(s) ______________, authorize (Name of physician / health care provider releasing records) to disclose to: Handi CapablewInc. 2450 Louisiana St. Ste 400-350 Houston, TX 77006 The release of ONLY the following specific protected health care information: _____ History/Physical _____ Discharge Summary _____ Operative Report _____ Pathology Report _____ Laboratory Report _____ ER Report _____ Other (specify) __________________________________________________ Entire medical record for specified date(s) of service: From: ___________________________ To: ______________________________ The purpose of the disclosure is: only information for ________________________ ____________________________________________________________________ I understand that information disclosed pursuant to this authorization may include information relating to the following, unless specifically restricted below: Please initial _____ Psychological/psychiatric conditions ____ HIV/AIDS diagnosis and/or testing _____ Drug and/or alcohol abuse diagnosis and/or treatment List any restrictions: _____________________________________________ _____________________________________________________________ Redisclosure of Information: I understand that once information is disclosed pursuant to this authorization that the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164, protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. Right to Refuse to Sign this Authorization: I understand that generally the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition my treatment, payment, or eligibility for health care benefits on my decision to sign this authorization. Right to Revoke: I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on it, or unless this authorization is given as a condition of obtaining health insurance coverage and the insurer has a legal right to contest the policy or a claim under the policy. To revoke this authorization, Expiration Date: I understand that unless I provide a written revocation at an earlier date, this authorization will expire in one year. Signature of Patient or Legal Representative(s): _________________________________________________________ Date: _____/_____/________Printed Name(s): _______________________________ Relationship to Patient:________________________________________ (if signed by other than patient)
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Text Box: Handi CapablewInc. Sylvia “Advocate For the Disabled Let’s talk Handi Capable4u@yahoo.com www.Handi-Capablesite.com Standing In The Gap For The Disabled 2450 Louisiana St. Ste 400-350 Houston, TX 77006-2380