LINK Program

LINK Program
Minority Health Consortium (MHC) is committed to helping individuals living with HIV connect to the care and support they need. Our team provides compassionate, confidential assistance to ensure every client is linked to medical care, treatment, and essential services that promote health, stability, and hope.

HIV Diagnosis Date*
Type of Screening*
Where did you receive your last HIV care:*
Place of HIV Diagnosis:*
Have you been discharged from the hospital in the last month?*

YesNo
Name of hospital:*
Have you recently been discharged from a correctional facility in the past month?*

YesNo
Name of correctional facility:*
Are you currently taking medication for HIV?*

YesNo
Have you ever taking medication for HIV?*

YesNo
Please list it here

Release to Contact Statement
I acknowledge that I am a person living with HIV and am seeking assistance in being connected to appropriate HIV medical care and supportive services. I understand that all information I provide will remain strictly confidential and protected in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and all applicable privacy laws.

By signing this form, I authorize Minority Health Consortium (MHC) to contact me by phone, email, or mail for the purpose of initiating the intake process and linking me to HIV-related care, treatment, and support services. I understand that this authorization allows MHC staff to collect only the information necessary to assist with my linkage to care and to ensure that I am connected with appropriate service providers.

I also understand that this consent is voluntary and may be revoked by me at any time in writing. However, I acknowledge that any actions taken based on this release prior to its revocation will remain valid.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Client Information