UEA Document Request & Consent

UEA Document Request & Consent
Client URN #
Client Provide #
Name*

First NameLast Name
Birth Date*

MonthDayYear
SSN*
Address*

Address

Street Address Line 2

CityState

Zip
Phone #*
Email Validator*

I have read and understand the Client's Rights & Responsibilities as well as the Grievance Procedures

Yes
I would like a copy of the Client's Rights & Responsibilities as well as the Grievance Procedures

YesNo

I give my permission to MHC and VDH to release records or information to necessary agencies to support the application or payment by Medicare, Medicaid, other health care benifits, or services through the Ryan White Part B Program.

Yes

Are you interested in learning more information about our support groups?*

YesNo