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UEA Document Request & Consent
Client URN #
Client Provide #
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
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December
Month
Please select a day
1
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31
Day
Please select a year
2026
2025
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2015
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1920
Year
SSN
*
Address
*
Address
Street Address Line 2
City
State
Zip
Email
*
Confirmation Email
example@example.com
Phone #
*
Format: (000) 000-0000.
Email Validator
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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
Yes
No
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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
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Are you interested in learning more information about our support groups?
*
Yes
No
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Are you accessing services today to complete Unified Eligibility Assessment?
*
Yes
Type a question
Target Date
-
Month
-
Day
Year
Date
Do you have transportation Issues?
*
Yes
No
Type a question
Target Date
-
Month
-
Day
Year
Date
Do you need assistance enrolling in insurance plain?
*
Yes
No
Type a question
Target Date
-
Month
-
Day
Year
Date
Do you have outstanding HIV medical bills?
*
Yes
No
Type a question
Target Date
-
Month
-
Day
Year
Date
Do you need assistance with finding Dental services?
*
Yes
No
Type a question
Target Date
-
Month
-
Day
Year
Date
Do you need assistance with finding Vision services?
*
Yes
No
Type a question
Target Date
-
Month
-
Day
Year
Date
Have you been unable to pay Rent Utilities or get food?
*
Yes
No
Type a question
By signing below, I give MHC permission to contact me to complete my Ryan White Eligibility.
*
Target Date
-
Month
-
Day
Year
Date
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: