Member Wellness Update

Name*

First Name Last Name

Aliveness Member Number

Four digits - also called an Access Pass

Address

Street Address

Street Address Line 2

City State

Zip Code

Phone Number

Email

example@example.com

Are you comfortable receiving mail from Aliveness?

YesNo

May Aliveness call you on the phone?

YesNo

My annual income is:*

If you have no personal income, how do you pay your expenses? Check all that apply.

My family member(s) are working or own a business.My family member(s) receive child support, SSI, SSDI, pension, etc.My family member(s) get money from a friend, relative, or organization.A relative, friend, or organization pays all my expenses.I pay my expenses from money in savings, checking, trust fund account, or the sale of personal items.Another source

Number of People in My Household:

Please include children, family, live-in partners if you share finances. If you live alone or support only yourself financially, you have a household of 1.

Please upload PROOF OF INCOME - examples: pay stubs, benefit letter, tax return, etc.

You are not required to provide proof if you have no income. You are also not required to provide proof if your income exceeds 400% of the Federal Poverty Guidelines (income over $51,040 for one person or over $68,960 for a two-person household). ALL members with income between 0 and $51,040 must upload a document to show your income.

Date of my last HIV/AIDS medical appointment*

Date

How often do you see your HIV/AIDS doctor?*

Every 3-6 monthsOnce a year (every 12 months)I am not currently receiving medical care and treatment for my HIV

What type of health insurance do you have? You can check more than one option.*

Please upload PROOF OF HEALTH INSURANCE - examples: a picture of your health insurance card, document showing active health insurance, etc.

What is your housing status?*

Stable/Permanent (rental, homeowner)Temporary (with friends/relatives, treatment facility, transitional housing)Unstable (homeless, staying in or out of shelter)

Please upload PROOF OF MINNESOTA RESIDENCY - examples: MN state ID, MN driver's license, picture of lease or utility bill

MEMBER POLICIES

Policies: HIPAA Policy/Client Confidentiality: The Aliveness Project will maintain your personal and demographic information in a confidential manner. Access to information about the services you receive will be limited to Aliveness Project staff and to others for whom you have provided written consent to share or discuss your information. This information will also be maintained in a confidential manner. You will not be identified or identifiable in any written reports or publications without your written consent. Consent for Aliveness Project staff to communicate with other Aliveness Project staff is automatic if you choose to become a member at The Aliveness Project. By agreeing to participate in programs at The Aliveness Project, you agree to provide information at the time of enrollment and periodically thereafter that will assist in data collection, assessment, and funding for services. For these purposes, personally-identifiable information will be provided to the Minnesota Department of Health (MDH) in accordance with contract agreements; however, The Aliveness Project and MDH will maintain your confidentiality as outlined below at all times. The goal of this is to make it easier for you to access additional services. The Minnesota Department of Human Services (DHS) and Hennepin County Ryan White Program will receive aggregate or group data only. The HIV/AIDS Bureau of the U.S. Department of Health and Human Services Health Resource and Service Administration (HRSA) does receive encrypted client level data that does not identify you by name or include any other identifying personal information. The data collected and reported to our funders is used to identify the services that individuals living with HIV/AIDS need and use, identify barriers to those services and unmet needs, and evaluate future funding needs. The Aliveness Project may also be required by state laws and regulations to release information about you in the following circumstances:

• If there is a subpoena or a court order mandating us to release your records for use in a court proceeding.

• If you are threatening to harm another person and you have stated both the identity of the person and the means by which you plan to harm that individual.

• If you are threatening to seriously harm yourself and have identified a means by which you plan to do so.

• If you are threatening to commit a serious crime or are suspected of committing a serious crime.

• If it is suspected that you are being maltreated by a caregiver or are not able to protect yourself from maltreatment.

• If there is a reason to believe you are abusing or neglecting a child or vulnerable adult.

New Hires / Case Management Clients: The Aliveness Project will follow the “Best Practices” when hiring personnel to be case managers or other service providers that work with confidential, data-sensitive information. Members who were or are currently case managed by an Aliveness Project medical case manager, work with outreach and prevention, or the nutritionist cannot become employees of those programs prior to at least 1 year separation from those services or, at the discretion of the Executive Director. Current members that are employees cannot be case managed or receive other services in a data-sensitive category at The Aliveness Project or have access to the Personal Medical Information of other clients. Anyone already in a dual-role position at the date this policy was enacted (03/27/2014) will be exempt from this policy.

Client Bill of Rights: Any client/member of The Aliveness Project is entitled to the following rights:

• The right to treatment with dignity and respect in a nonjudgmental manner, regardless of HIV status, race, ethnicity, gender, religion, age, country of origin, sexual orientation, or physical/mental disability.

• The right to keep one’s HIV status and other personal information confidential. Information will be withheld from all inquirers, including family members, spouse/partner, friends, medical providers, or law enforcement personnel except in cases of life-threatening situations, child abuse, or with the written request of the client.

• The right to receive services whether or not a member is currently receiving medical care for HIV/AIDS. • The right to refuse or discontinue services at any time for any reason. This includes the right to inspect all client-specific documents, including intake forms, assessment forms, case notes and any other documents pertaining to the client only.

• The right to information pertaining to the grievance and appeals process in the event that a member has a dispute with a staff person or service provider of The Aliveness Project. • The right to be protected from sexual, verbal and/or physical harassment from staff or other service providers.

• The right to be protected from discharge from membership without due cause, notice and/or process. • The right to receive interpretation/translation services (for clients with limited English proficiency or hearing impairment), if no staff speaks the client’s language or the client has not arranged for an interpreter.

Non-discrimination Policy: It is the policy of The Aliveness Project that services will be provided to all individuals without discrimination on the basis of HIV status, race, religion, color, age, sex, gender, sexual orientation, religion, national origin, physical or mental disability, or any basis prohibited by law.

Grievance Policy: You have the right to file a grievance if you feel you have been treated unfairly in any way. You will suffer no repercussions in service delivery solely as a result of filing a grievance. All grievances will be addressed in a confidential manner. If you have a grievance, you should first discuss it with the staff person with whom you are working. If this is not successful or if you feel that this is not an option, you should proceed with the following steps:

1. A written statement may be prepared (including date and time of incident) of the grievance. If you prefer, a grievance may be communicated verbally.

2. Submit the grievance to the staff person’s supervisor. An appointment will be scheduled for you to meet with the supervisor to resolve your grievance. If the matter cannot be mediated, your grievance may be referred to the Executive Director for final resolution.

3. Grievances will receive prompt attention. Every effort will be made to address and resolve grievances within ten (10) business days. Written correspondence can be mailed or delivered to: 3808 Nicollet Avenue, Mpls., MN 55409.

Client’s Consent for Services: I acknowledge that I have read and understand the above information and agree to receive services provided by The Aliveness Project under the conditions stated above. I may, without consequence, withdraw my participation from this organization’s services at any time. I may request and receive a copy of this signed consent form at any time. Any and all copies of this document are to be considered as binding as the original.

Signature (use your finger or mouse to sign)*

Clear

Date Submitted*

Date