Client Notification Regarding Consent Form for Eligibility Processing

Please inform the client that a representative from MHC will be reaching out to obtain their signature on the Provide Enterprise Consent Form. This form authorizes MHC to conduct the client's eligibility assessment on behalf of the Virginia Department of Health (VDH), your agency, and the client, facilitating the provision of necessary services.

Client Acknowledgment & Certification

By signing and submitting this form, I affirm that the information I have provided is accurate, complete, and truthful to the best of my knowledge. I understand that this information is essential for determining my eligibility for services under the Minority Health Consortium’s Ryan White Program.

I acknowledge that knowingly providing false or misleading information may result in delays, denial of services, or removal from the program, and could carry legal consequences. I also understand that I may be asked to submit additional documents or clarification to support the details shared in this form.

My signature indicates that I am submitting this information willingly and in good faith, and that I am committed to working in partnership with the MHC team to access the care and support I need. I appreciate the dedication of the staff and the care being taken to ensure fair and accurate assessments for all clients.