Fillable BRAP Application - 04 17 2018 (2)

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BRAP Application - 04 17 2018 (2)

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BRAP APPLICATION CHECKLIST
The following items are required for your application to be processed:
BRAP application
Priority Documentation (Priorities are listed on Pages 3 & 4)
o If applying as homeless it needs to be witnessed & documented within 7 days
Social Security Benefit Statement, or documentation showing you have applied
o Documentation must be dated within 30 days of the application
o If you get any other source of income, we must have the documentation as part of
your application
o All household members listed on the application must provide proof of any
income or a statement of no income
Section 17 eligibility
o
Either a valid Kepro authorization for a Section 17 service (BHH will not be
accepted), or the BRAP Enrollment Form ( Pages 6 & 7) completed
Section 8 wait list status
o Documentation must be dated within 30 days of the application
All incomplete applications will result in the application being returned and/or denied for subsidy. This
includes completed applications without supporting documentation or verifications.
If you have any questions regarding this application, please contact the Rental Services Office at
Kennebec Behavioral Health at 873-2136.
Walk in hours are Tuesdays from 10am – 12pm or Thursdays from 1pm – 3pm in the
Waterville Office, or you can call to make an appointment.
Revised 04/13/2018
SUBMITTING YOUR COMPLETED APPLICATION
For more information or to submit a completed application, please contact one of the following agencies depending on
County preference.
ANDROSCOGGIN, FRANKLIN, AND OXFORD COUNTIES
Common Ties
P.O. Box 1319
Lewiston, ME 04243
Tel. 207-795-6710 Fax: 207-795-6714 (Attn: Housing)
AROOSTOOK COUNTY
AMHC
One Edgemont Drive
Presque Isle, Maine 04769
Tel. 207-764-3319 Fax: 207-768-5377 (Attn: BRAP)
YORK AND CUMBERLAND COUNTIES (except Brunswick, Harpswell, and Freeport)
Shalom House, Inc.
106 Gilman Street
Portland, ME 04102
Tel. 207-874-1080 Fax: 207-874-1077 (Attn: BRAP)
HANCOCK, PENOBSCOT, PISCATAQUIS, AND WASHINGTON COUNTIES
Community Health & Counseling Services
P.O. Box 425
Bangor, ME 04402-0425
(42 Cedar Street, Bangor, ME 04401)
Tel. 207-947-0366
KENNEBEC AND SOMERSET COUNTIES
Kennebec Behavioral Health
67 Eustis Parkway
Waterville, ME 04901
Tel. 207-873-2136 Fax: 207-660-4532
KNOX, LINCOLN, SAGADAHOC, WALDO COUNTIES (Cumberland County: Brunswick, Harpswell, and
Freeport)
Sweetser Mental Health Services
329 Bath Road, Suite 1
Brunswick, ME 04011
Tel. 207-373-3049 or 207-373-3118 Fax: 207-373-3105
Page 1 of 10 Revised 04/13/2018
BRIDGING RENTAL ASSISTANCE PROGRAM (BRAP)
APPLICATION
First Name: Last Name: ___________________________________
Gender: Male Female Transgender MTF Transgender FTM Gender Non-Conforming
Social Security Number: _______________________
DOB:______________________
Veteran: YES
NO Are you Hispanic or Latino? Yes No
Race (check all that apply):
American Indian or Alaskan Native Asian
Black or African-American Native Hawaiian or Pacific Islander
White or Caucasian Other: _______________________
Mailing Address:
Telephone Number: ____________________________
Preferred Counties (1
st
& 2
nd
choice): ____________________________________________________
1
. Is the applicant an AMHI Consent Decree Class Member? YES NO
*(A Consent Decree Class Member is someone who was hospitalized at AMHI/Riverview Psychiatric
Center on, or after January 1, 1988.)
2. Does Applicant meet Eligibility For Care for Community Support Services?
*(As defined in Section 17 of the MaineCare Benefits Manual effective 4/08/2016) YES
NO
*If you answered ‘no’ to questions #1 and #2 you are not eligible for assistance under BRAP
3. Is the applicant currently receiving SSI or SSDI (Attach documentation dated within 120 days of
application date)? YES
NO
4. If no, are you in the process of applying for or appealing SSI or SSDI (Attach documentation of
application or appeal)? YES
NO
*If you answered ‘no’ to questions #3 and #4 you are not eligible for assistance under BRAP
5
. Is applicant currently on a waitlist for federally subsidized housing? YES NO
5A. If ‘No’ why?_____________________________________________________________
**ATTACH VERIFICATION FROM THE HOUSING AUTHORITY OR MANAGEMENT COMPANY
WHERE YOU APPLIED FOR SUBSIDIZED HOUSING AND/OR SECTION 8.
Page 2 of 10 Revised 04/13/2018
6. Correspondence: Do you want us to copy all correspondence (i.e., acceptance letter, denial letter, debt
information) to your referral source or other service provider? If yes, please provide name, address, and
phone number for all that apply.
Payee: YES
NO
Case Manager: YES NO
Guardian: YES NO
Service Provider: YES NO
7. Household Composition: # of Household Members who will be residing in the unit: _____
*Please note: Each additional Household Member must complete and attach a Household Member Form
Name: Relationship to Applicant: Pregnant:
Yes No
Yes No
Yes No
Yes No
8. Applicant Income & Other Assistance Sources:
Documentation of current monthly income must be attached.
Income Sources Other Assistance Sources
No financial resources $___________
None
Supplemental Security Income (SSI) $___________
SNAP / Food Stamps
Social Security Disability Income (SSDI) $___________
Medicare
Social Security $___________
Medicaid (MaineCare)
Employment income $___________
SCHIP
General Public Assistance (GA) $___________
VA Medical Services
Unemployment benefits $___________
WIC
Temporary Aid Needy Families (TANF) $___________
TANF (Child Care / Transp.)
State Supplement $___________
Indian Health Services
Other (Source): _______________ $___________
Employer Provided Insurance
Other (Source): ___________
TOTAL Monthly INCOME: $___________
Page 3 of 10 Revised 04/13/2018
9. Please indicate priority and ATTACH VERIFICATION for all that apply:
#1 Psychiatric Discharge: BRAP Applicants who are being discharged from Riverview
(RPRC) or Dorothea Dix (DDPC), or private psychiatric hospital after a 72-hour or
greater admission, or who have been discharged in the past thirty (30) days from any of
such institutions. Also, BRAP Applicants who are moving, or have been discharged in
the past thirty (30) days, from a State funded Residential Treatment program (Mental
Health PNMI) to less restrictive accommodations, to allow for appropriate discharges
from the institutions mentioned above. Attach intake and/or discharge paperwork from
program.
#2 Homeless: BRAP Applicants who are Literally Homeless, as defined by HUD, on a
ranked basis according to length of homelessness, with those being homeless the longest
as the top priority. Attach verification of living situation written on agency letterhead
stating location, length of stay and dates of homelessness; include title of person
completing the verification. Last documented incidence must be dated within fourteen
(14) days of application submission.
#3 BRAP Applicant is being discharged within the next thirty (30) days from a correctional
facility (Jail/Prison); or has been adjudicated through a Mental Health treatment court and
meets Section 17 criteria and no subsequent residences have been identified and they lack
the resources and support networks needed to obtain access to housing. Attach
verification of stay written on agency letterhead stating location, and dates of stay;
include title of person completing the verification.
Please Note: In addition to the priorities stated, BRAP may be extended to specific projects and/or
populations as determined by the Department.
Non-Discrimination Notice
The Department of Health and Human Services (DHHS) does not discriminate on the basis of disability, race, color, creed,
gender, sexual orientation, age, or national origin, in admission to, access to, or operations of its programs, services, or activities,
or its hiring or employment practices. This notice is provided as required by Title II of the Americans with Disabilities Act of
1990 and in accordance with the Civil Rights Act of 1964 as amended, Section 504 of the Rehabilitation Act of 1973, as
amended, the Age Discrimination Act of 1975, Title IX of the Education Amendments of 1972 and the Maine Human Rights Act
and Executive Order Regarding State of Maine Contracts for Services. Questions, concerns, complaints or requests for additional
information regarding the ADA may be forwarded to DHHS’ ADA Compliance/EEO Coordinators, 11 State House Station – 221
State Street, Augusta, Maine 04333, 207-287-4289 (V), 207-287-3488 (V), 1-800-606-0215 (TTY). Individuals who need
auxiliary aids for effective communication in program and services of DHHS are invited to make their needs and preferences
known to the ADA Compliance/EEO Coordinators. This notice is available in alternate formats, upon request.
Applicants are encouraged but not required to engage in services as a condition of acceptance into the Bridging Rental Assistance
Program.
Page 4 of 10 Revised 04/13/2018
10. CERTIFICATIONS:
_______ Initials Any previous BRAP recipient may re-apply for the subsidy, as long as he or she is
eligible and in good standing with the BRAP program. Applicants who owe the BRAP program back rent,
damages, security deposit, etc., may be considered for readmission provided that one of the following
minimum criteria have been met:
· 100% of account balance must be paid before move in or unit transfer, not to exceed
thirty (30) days; or
· Establishment of a legally assigned Representative Payee within thirty (30) days and
a documented payment plan not to exceed twelve (12) months.
Failure to meet at least one of the above criteria may result in program ineligibility and termination of
rental assistance.
_______ Initials Section 8 compliance: I understand that one of the eligibility criterion for BRAP is
that I must maintain an active application for federally assisted housing during my entire tenure with
BRAP, with a local Public Housing Authority or Administrator. If a wait list is closed, I understand that I
am obligated to get on the list at the earliest opening date. I understand that if I do not comply with this
and other requirements detailed in the Tenant Responsibility Agreement, I may be immediately
terminated from BRAP.
________ Initials Release of Information: I/We agree to complete the necessary release(s) of
information which will allow____________________(Name of LAA) to obtain, verify, and document
information pertaining to initial and ongoing eligibility for rental assistance provided under this program.
_______ Initials Release of information: I/we agree to have any and all correspondence relating to
initial and ongoing eligibility for rental assistance copied to my guardian and/or representative payee
and/or other designated person as identified in Question 6.
________ Initials Tenant’s Certification: I/We certify that the information contained in this application
is true and complete to the best of my/our knowledge and belief. Failure to furnish true, accurate, and
complete information, now or in the future, will result in one or more of the following: termination from
program, eviction, formal investigation, legal action. Intentionally submitting false or incomplete
information, including but not limited to submitting false household income and/or composition, is a
crime.
________ Initials If you were homeless prior to enrolling in BRAP: The Bridging Rental Assistance
Program, you are a participant in the statewide Homeless Management Information System (HMIS).
Participation in the BRAP program means your information and the information of your household
members will be submitted to a secure database so that Maine can generate mandated federal reports
about homelessness.
Print Applicant Name Applicant Signature Date
Print Name–Other Adult Member Other Adult Member Signature Date
Page 5 of 10 Revised 04/13/2018
ELIGIBILITY VERIFICATION
1. I hereby affirm the above-enclosed information concerning current housing situation, current
address, and eligibility criteria are true and accurate for this client as indicated above; and
2. I verify the Applicant meets the Eligibility For Care for Community Support Services as defined
in Section 17 of the MaineCare Benefits Manual or is already enrolled in PNMI services:
CHECK APPROPRIATE BOX and ATTACH VERIFICATION:
i. Applicant is already enrolled in Adult Mental Health Services funded Community
Support (Section 17) and/or PNMI services (Section 97)—verification of
enrollment with KEPRO HealthCare or DHHS attached; OR
ii.
No KEPRO HealthCare or DHHS Adult Mental Health Enrollment form is currently
on file. I have attached a completed BRAP Enrollment Form to provide a mental
health diagnosis or have attached such a signed qualifying diagnosis my agency
deems appropriate to document eligibility for services under Section 17 as may be
approved by KEPRO HealthCare and/or DHHS to the BRAP Enrollment Form.
Referring Agency:
_____________________________ ______________________________ ________________
Printed Name Signature Date
_____________________________________________________________________________________
LAA OFFICE USE ONLY
Representative Signature: ____________________________ Date: ___________________
Program: Slot assigned: / / Slot Size:
Date Housed in program: / / Worker Assigned:
Office of Adult Mental Health Services
BRAP ENROLLMENT FORM
To be completed ONLY for persons not already Enrolled in Section 17 Services AFTER April 7, 2016
Birth:
Client Information:
Name:
Date of
Social Security Number:
Diagnosis and LOCUS Information:
Primary
Diagnosis:
Date Given:
LOCUS Score:
Rater ID:
Date Given:
Requirements for Eligibility. A person is eligible to receive covered services if he or she meets both general
MaineCare eligibility requirements and specific eligibility requirements for Community Support Services
under Section 17 of the MaineCare Benefits Manual.
General Requirements. Individuals must meet the eligibility criteria as set forth in the MaineCare Eligibility
Manual. Some members may have restrictions on the type and amount of services they are eligible to receive.
Risk Factors: Documented or reported history, stating that he/she is likely to have future episodes, related to
mental illness, with a non-excluded DSM 5 diagnosis.
Specific Requirements. A member meets the specific eligibility requirements for covered services under
this section if:
A. The person is age eighteen (18) or older or is an emancipated minor with:
1. A primary diagnosis of Schizophrenia or Schizoaffective disorder in accordance with the DSM 5
criteria; or
2. Another primary DSM 5 diagnosis or DSM 4 equivalent diagnosis with the exception of
Neurocognitive Disorders, Neurodevelopmental Disorders, Antisocial Personality Disorder and
Substance Use Disorders who:
a) has a written
opinion fr
om a clinician, based on documented or reported history, stating that
he/she is likely to have future episodes, related to mental illness, with a non-excluded DSM 5
diagnosis, that would result in or have significant risk factors of homelessness, criminal justice
involvement or require a mental health inpatient treatment greater than 72 hours, or residential
treatment unless community support program services a
re provided; based on documented or
reported history
; for the purposes of this section, reported history shall mean an oral or written
history obtained from the member, a provider, or a caregiver; or
b) has received treatment
in a state psychiatric hospital, within the past 24 months, for a non-
excluded DSM 5 diagnosis; or
c) has been discharged from a mental health residential facility, within the past 24 months, for a
non-excluded DSM 5 diagnosis; or
d) has had two or more episodes of inpatient treatment for mental illness, for greater than 72
hours per episode, within the past 24 months, for a non-excluded DSM 5 diagnosis; or
e) has been committed by
a civil court for psychiatric treatment as an adult; or
f) until the age of 21, the recipient was eligible as a child with severe emotional disturbance, and
the recipient has a written opinion from a clinician, in the last 12 months, stating that the
recipient had risk factors for mental health inpatient treatment or residential treatment, unless
ongoing case management or community support services are provided.
AND
Page 6 of 10
Revised 04/13/2018
B. Has significant impairment or limitation in adaptive behavior or functioning directly related to the
primary diagnosis and defined by the LOCUS or other acceptable standardized assessment tools
approved by the Department. If using the LOCUS, the member must have a LOCUS score, as
determined by a LOCUS Certified Assessor, of seventeen (17) (Level III) or greater, except that to be
eligible for Community Rehabilitation Services (17.04-2) and A
CT (17.04-3), the member m
ust have
a LOCUS score of twenty (20) (Level IV) or greater.
C. Eligible members who are eighteen (18) to twenty-one (21) years of age shall elect to receive services
as an adult or as a child. Those members electing services as an adult are eligible for services under
this Section. Those electing services as a child may be eligible for services under Chapter II, Section
65, Behavioral Health Services or Section 13 or both.
D. The LOCUS or other approved tools must be administered, at least annually, or more frequently, if
DHHS or an Authorized Entity requires it.
History Of (check all which apply):
Has received treatment in a state psychiatric hospital, within the past 24 months;
Has been discharged from a mental health residential facility, within the past 24 months;
Has had two or more episodes of inpatient treatment for mental illness, for greater than 72 hours
per episode, within the past 24 months;
Has been committed by a civil court for psychiatric treatment as an adult;
Until the age 21, the recipient was eligible as a child with severe emotional disturbance.*
∗ If selecting this qua
lifier, please indicate a written opinion stating that the recipient, in the last 12
months, had risk factors for mental health inpatient treatment or residential treatment, unless ongoing
case management or community support services are provided.
Based on documented or reported history**, stating that he/she is likely to have future episodes,
related to mental illness, with a non-excluded DSM 5 diagnosis, that would result in or have
significant risk factors of (check all which apply):
Homelessness;
MH Residential treatment;
MH inpatient greater than 72 hours;
Criminal Justice involvement.
** Reported history may include oral or written history from the client, a provider, or a caregiver
Signatures and Certifications:
I, , certify and attest that the diagnostic
Clinician Signature
information listed on the previous page (7) are in accordance with the Specific Requirements section of
this form (Part A, paragraph 2, sub-paragraph a) and is true and complete to the best of my knowledge
and belief.
Print Name and Credentials
(must be MD, LCSW, LCPC, PhD, APRN, NPC, PA or DO)
Date:
Page 7of 10
Revised 04/13/2018
Page 8 of 10
Revised 04/13/2018
MAINE HOMELESS MANAGEMENT INFORMATION SYSTEM
AUTHORIZATION FOR DISCLOSURE OF HEALTH AND/OR PERSONAL INFORMATION
For:
(First Name)
(Middle)
(Last Name) (Date of Birth)
READ FIRST: _______________ ("Participating Agency") participates in a federally funded Maine State
Housing Authority ("MaineHousing") program for persons who are homeless. Such participation includes
collecting and entering into a Maine Homeless Management Information System ("HMIS") certain personal
and demographic information Participating Agency maintains for homeless persons it serves, and such
information can also include health care information (such as needs assessment information used to establish
your level of housing needs and services) if Participating Agency is a licensed health care provider.
Information entered and maintained in the HMIS about you can then be accessed and used by
MaineHousing and other participating agencies to evaluate outcomes and the effectiveness of
MaineHousing’s program in reducing homelessness. Authorizing Participating Agency to collect and enter
into the HMIS personal and health care information about you may reduce or eliminate the need for you to
be screened repeatedly by each participating agency from which you seek services (i.e., minimize the number
of times you have to "tell your story"), allow you to receive services more quickly, and enhance
MaineHousing's and participating agencies' ability to provide you with more effective coordinated services to
meet your housing needs. If you wish to authorize Participating Agency to disclose your personal and/or
health care information to MaineHousing and other participating agencies through the HMIS, please
complete and sign this form. Participating agencies who are "covered entities" under HIPAA, may use and
disclose your health care information only for purposes authorized by the federal HIPAA Privacy Standards
and applicable Maine health care confidentiality law, pursuant to this authorization, and pursuant to each
participating agency's own Notice of Privacy Practices, which is posted at each participating agency and
should be offered to you by each participating agency from which you obtain services.
By signing below, I acknowledge, understand and agree that:
My and my dependent children's (identified below) personal and health care information and records are protected by
federal and state laws and regulations governing the confidentiality of client records and cannot be disclosed without
my written authorization unless otherwise provided for in such laws and regulations. All agencies that participate in
the Maine HMIS have an obligation to keep confidential my personal information, identifying information, records,
and any health care information, they maintain about me and my dependent children as listed on this form below.
Unless I strike out this sentence, I intend for this authorization to include disclosure of (i) any mental and behavioral
health information maintained by any participating agency that is a licensed mental health agency, facility or
program (which I have the right to review at any reasonable time before deciding to authorize its disclosure on this
form); (ii)any mental and behavioral health information related to mental health services provided to me by licensed
mental health professionals (i.e., psychiatrists, psychologists, clinical nurse specialists, social workers and counseling
professionals) at a participating agency; and (iii) any HIV information maintained about me by any participating
agency (which disclosure of HIV information could have adverse consequences, including loss or denial of
employment, health insurance benefits, life insurance benefits, and other forms of discriminatory treatment,
whether lawful or unlawful).
Unless I strike out any of the following, I intend this authorization to include (i) the disclosure of records and
information the disclosing agency has received from other agencies, healthcare providers or facilities, and (ii)
subsequent disclosures of information that are within the scope of this authorization.
This authorization is also intended to include disclosure of my historical record contained within the HMIS.
I authorize the disclosures permitted by this authorization to be made through the HMIS, by fax, mail or orally, as
Page 9 of 10
Revised 04/13/2018
deemed most appropriate by the parties authorized to share my information.
None of the parties authorized to share my information under this authorization will receive any payment or other
remuneration in exchange for disclosing my information, except as may be allowed by law.
I may refuse to authorize the disclosure of some or all of the personal or health care information described on this form
concerning me or any of my listed dependents below to any of the other collaborating Maine HMIS participating
agencies. However, I understand that my refusal could result in improper services or other adverse consequences.
Participating Agency will not condition services or treatment on whether I sign this authorization.
I may revoke this authorization at any time, in writing, by notifying the Participating Agency in the manner described
in Participating Agency's Notice of Privacy Practices, except to the extent that Participating Agency or other persons
or entities have already acted in reliance on it. Revocation WILL NOT
be retroactive.
There is the potential that information disclosed pursuant to this authorization may be redisclosed by persons or
entities receiving the information and that, as a result, the information may no longer be protected.
Data derived from my information will be used by MaineHousing to report to funders, the Maine Department of Health
& Human Services, and for advocacy purposes.
All information collected on the Client Profile, Entry, Interim, and Exit Assessments, and the Shelter/Home to
Stay prioritization tool will be shared with MaineHousing and other participating agencies through the HMIS to aid
and assist service providers in obtaining housing and services for me and/or my
household.
I have a right to a copy of this signed authorization.
I have read the foregoing information, or it has been read to me, and I have had the opportunity to
ask questions about it and any
questions that I have asked have been answered to my satisfaction.
By signing below, I give permission to the Participating Agency identified above to disclose to and obtain from
MaineHousing and the other Maine agencies participating in the Maine HMIS identified on Exhibit A attached, any
personal information and health care information that any of these participating agencies maintain about me, or about
any of my dependent children who are not authorized by law to authorize such disclosure on their own behalf. I
authorize such disclosures for purposes of evaluating my housing service needs, coordinating the delivery of housing
services to me, for evaluating outcomes and the effectiveness of the MaineHousing’s emergency shelter homeless
program in reducing or eliminating homelessness, and for the other uses and purposes described elsewhere on this
form above.
This authorization will automatically expire in thirty (30) months, unless I revoke it earlier. To the extent that this
authorization authorizes disclosure of any mental health information maintained by a licensed mental health agency,
facility or program, this authorization will automatically expire in one (1) year with respect to the disclosure of such
mental health information, unless I revoke it earlier.
Signature of Client, Guardian, Health Care Power of Attorney
Date
or Health Care Surrogate
Provider Use:
___________________________________ did not give permission to share and exchange
information with other Maine HMIS participating agencies for the purpose of evaluating
services needed and to coordinate service delivery.
__________________________ gave limited permission to share and exchange information
with other Maine HMIS participating agencies for the purposes of evaluating services needed
and to coordinate service delivery.
EXHIBIT A
Maine Homeless Management Information System
AUTHORIZATION FOR DISCLOSURE OF HEALTH AND/OR PERSONAL INFORMATION
PARTICIPATING AGENCIES
Aroostook Mental Health Services, Inc.
The Bangor Area Homeless Shelter
Bread of Life Ministries, Inc.
Catholic Charities Maine
City of Portland
Area IV Mental Health Services Coalition (Common Ties Mental Health Center)
Community Health and Counseling Services
Community Housing of Maine, Inc.
Employment Specialists of Maine, Inc.
H.O.M.E., Incorporated
Homeless Services of Aroostook
Kennebec Valley Mental Health Center
Knox County Homeless Coalition
Maine Department of He
alth and Human Services
Maine State Housing Authority
Mid-Maine Homeless Shelter, Inc.
New Beginnings, Inc.
Penobscot Community Health Center
Preble Street
Portland Housing Authority
Rumford Group Homes, Inc.
Rural Community Action Ministry
Shalom House, Inc.
Shaw House
Sweetser
Tedford Housing
York County Shelter Programs, Inc.
Washington Hancock Community Agency
Western Maine Homeless Outreach
YANA Inc.
U.S. Department of Veterans
Affairs
Veterans Inc.
Volunteers of America Northern New England, Inc.
*Applicant Initials:
Page 10 of 10
Revised 04/13/2018
Revised 4/13/2018
DHHS SUBSIDY PROGRAMS
BRAP / SPC Household Member Form
Instructions: Please complete a Household Member form for each additional household member who will be residing in the unit.
*If form is not completely filled out, the LAA reserves the right to return the application.
1. Household Member Name: __________________________________________
2. Program: BRAP Shelter Plus Care
3. Relationship to HOH: ___________________________________
4. Gender: M F Transgender M to F Transgender F to M Gender Non-Conforming
5. Date of Birth: ___________________ 6. Social Security Number: _____________________
7. Are you a Veteran? Yes No
8. Are you Hispanic or Latino? Yes No
9. Race (check all that apply):
American Indian or Alaskan Native Asian
Black or African-American Native Hawaiian or Pacific Islander
White or Caucasian Other: _______________________
10. Do you have a Disabling Condition? Yes No
If yes:
Severe Mental Illness HIV/AIDS Developmental Disability
Alcohol Abuse Drug Abuse
Chronic Health Condition Physical Disability
11. Income and Other Assistance Sources: Documentation of current monthly income must be attached.
Income Sources: Monthly Amount: Other Assistance Sources:
No Financial Resources $_____________ None
Supplemental Security Income (SSI) $_____________ SNAP/Food Stamps
Social Security Disability Income (SSDI) $_____________ Children’s State Health Program (SCHIP)
Social Security Retirement $_____________ Medicare
Employment income $_____________ MaineCare
General Public Assistance (GA) $_____________ Veterans Health Care
Unemployment Benefits $_____________ Employer-Provided Health Insurance
Temporary Aid Needy Families (TANF) $_____________ Indian Health Services
State Supplement $_____________ WIC Insurance
Other (Source): ____________________ $_____________ Other (Source): ________________
TOTAL MONTHLY INCOME: $_____________
Revised 4/13/2018
12. Where are you currently residing?
Length of Stay: _______________ | Zip Code: _______________
13. If coming from a Homeless Situation:
How many separate times have you been on the streets or in a shelter in the past 3 years? ___________
Approximate Date Homelessness Started: _____/_______/______
14. Are you a victim or survivor of domestic violence? Yes No
14a. If yes, when: Within the past three months ago Three to six months ago
From six to twelve months ago More than a year ago
Don’t Know Refused to Answer
14b. If yes, are you currently fleeing? Yes No Refused
Tenant’s Certification: By signing below, I certify that the information contained in this form is true and complete to the
best of my knowledge and belief.
APPLICANT or HOUSEHOLD MEMBER (18+) or GUARDIAN SIGNATURE DATE
Place not meant f
or habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport,
tent, camping site, or anywhere outside)
Emergency shelter, including hotel or motel paid for with emergency shelter voucher
Sa
fe Haven
Foster care home or foster care group home
Hospital (non-psychiatric)
Jail, prison or juvenile detention facility
Long-Term Care Facility or Nursing Home
Psychiatric hospital or other psychiatric facility
Substance abuse treatment facility or detox center
Hotel or motel paid for without emergency shelter voucher
Owned by client, no ongoing housing subsidy
Permanent housing for formerly homeless persons (such as SHP, S+C, or SRO Mod Rehab)
Rental by client, no ongoing housing subsidy
Rental by client, with VASH housing subsidy
Rental by client, with other (non-VASH) ongoing housing subsidy
Staying or living in a family member’s room, apartment or house
Staying or living in a friend’s room, apartment or house
Transitional housing for homeless persons (including homeless youth)
Monthly Maximum Social Security Income Payment
I, self-certify that I receive a Social Security Income
Tenant or household member
Payment of $ that meets the published monthly standard Social Security Payment.
(amount being received)
I certify that the information above is true and complete to the best of my knowledge and
belief. Failure to furnish true, accurate, and complete information, now or in the future, will result
in one or more of the following: termination from program, formal investigation, and legal action.
Intentionally submitting false or incomplete information, including but not limited to submitting false
household income and/or composition, is a crime.
Tenant or household member Signature Date
LAA Representative Signature Date
State Supplement
I, □DO □ DO NOT receive the $ State Supplement
Tenant or household member (dollar amount)
I certify that the information above is true and complete to the best of my knowledge and
belief. Failure to furnish true, accurate, and complete information, now or in the future, will result
in one or more of the following: termination from program, formal investigation, and legal action.
Intentionally submitting false or incomplete information, including but not limited to submitting false
household income and/or composition, is a crime.
Tenant or household member Signature Date
LAA Representative Signature Date
Statement of No Income
Instructions: Please complete this form for each adult household member who has no income source.
Household Member Name:
Are you the head of household? Yes No
If No, Name of Head of Household:
I am NOT receiving any income at this time. I understand that I am responsible for:
1. Reporting any income I receive; and
2. Paying a portion of my income as rent.
I agree to contact my Subsidy Representative when I begin to receive income. Failure to report
any or all income in a timely manner may result in loss of eligibility to participate in this program.
Please provide a brief explanation of what efforts are currently being taken to gain income. If
you have applied for benefits, include the approximate date of application.
Tenant/Household Member Date
LAA Representative Date
Revised
11/1/2010
Waterville Clinic and
Administrative Offices
67 Eustis Parkway
Waterville, Maine
04901-5173
207-873-2136
1-888-322-2136
207-872-4522 Fax
Augusta Clinic
66 Stone Street
Augusta, Maine
04330-5227
207-626-3612 Fax
16 Caldwell Road
Augusta, Maine
04330-5500
207-626-3455
Skowhegan Clinic
5 Commerce Drive
Skowhegan, Maine
04976-1828
207-474-8368
207-474-7794 Fax
Winthrop Clinic
736 Old Lewiston Rd
Winthrop, Maine
04364-4121
207-377-8122
207-377-8564 Fax
www.kbhmaine.org
MEMO TO ALL BRAP RECIPIENTS
Due to recent changes with the Section 8 Wait List our office is no longer
able to verify your status. In order to stay in compliance with the Bridging
Rental Assistance Program you will need to provide this documentation. If
you do not have access to a computer you may utilize your local library or
your local housing authority.
This is the link to the website. mainesection8centralwaitlist.org
Waterville Housing Authority
873-2155 88 Silver Street Waterville, ME 04901
Augusta Housing Authority
626-2357 33 Union Street Suite 3 Augusta, ME 04330
Maine State Housing Authority
626-4600 353 Water Street Augusta, ME 04330
If you have any questions, please our office 873-2136 ext. 1550.
Rental Services Fax # 660-4532
Sincerely,
Rental Services Office
Kennebec Behavioral Health
Administrative
Offices & Clinic
67 Eustis Parkway
Waterville, Maine
04901-5173
207-873-2136
1-888-322-2136
207-872-4522 Fax
Augusta Clinic
66 Stone Street
Augusta, Maine
04330-5227
207-626-3455
207-626-3612 Fax
16 Caldwell Road
Augusta, Maine
04330-5227
207-626-3455
Skowhegan Clinic
5 Commerce Drive
Skowhegan, Maine
04976-1828
207-474-8368
207-474-7794 Fax
Winthrop Clinic
736 Old Lewiston Rd
Winthrop, Maine
04364-4121
207-377-8122
CONSENT FOR RELEASE OF INFORMATION
To: Dept. of Human Services ATTN:
Name_
Date of Birth_
Social Security Number
I authorize the Department of Human Services to release information or records about
me to:
Kennebec Behavioral Health
Rental Services
67 Eustis Parkway
Waterville, ME 04901
Please send PRINTED notification to the above address.
207-377-8564 Fax
Amount of SSI monthly supplement (if known)
www.kbhmaine.org
National Alliance
on Mental Illness
Commission on
Accreditation of
Rehabilitation Facilities
Amount of State Supplement
Amount of monthly TANF payment
USF & G Insurance payment amount
I want this information released to the above named individual or organization to verify
my income. I am either an applicant for a federally or state funded housing program
administrated by Kennebec Behavioral Health or already a tenant having an annual re-
certification. The information released will be used to determine my eligibility status and
the amount of my rent.
I am the individual to whom the information/record applies or that person’s parent (if a
minor) or legal guardian.
Signature_
Date_ Relationship
09/18/2015
DHHS Authorization Form 2/17
Page 1 of 2
Authorization to Release Information
We are committed to the privacy of your health information. Please read this form
carefully.
Office of MaineCare Services
Substance Abuse and Mental Health Services
Office for Family Independence including Medical Review Office of Child and Family Services
Maine Centers for Disease Control and Prevention Office of Aging and Disability Services
Dorothea Dix Psychiatric Center
Office of Administrative Hearings
Riverview Psychiatric Center
Other:
Individual’s Name:
Individual’s Date of Birth:
Individual’s Social Security Number:
Individual’s Address:
Street Town/City State Zip Code
Records to be released, including written, electronic and verbal communication:
All Healthcare, including
treatment, services, supplies and medicines
Claims Information Billing, payment, income, banking, tax, asset, and/or other information regarding
eligibility for DHHS program benefits such as MaineCare
Other: RENTAL ASSISTANCE & HOUSING INFORMATION
Limit to
the following date(s) or type(s)
of i
nformat
ion:
(e.g. “lab test dated June 2, 2016” or “hospital records from 1/1/16 - 1/15/16”)
I authorize the DHHS office(s) chec
ked above to: Release my information to: Obtain my information
from: Name:
Kennebec Behavioral Health
Address:
67 Eustis Parkway, Waterville, ME 04901
Street
Town/City State Zip Code
Fax No., where applicable: 207-660-4532
Phone No. to verify Receipt of Fax
207-873-2136
By initialing below, I agree to disclose the following types of information from my records:
Mental health services
Drug or alcohol use/abuse program services
HIV infection status or test results: Maine law requires us to tell you that releasing this information may
have implications. Positive implications may include giving you more complete care, and negative implications may
include discrimination if the data is misused. DHHS will protect your HIV data, and all your records, as the law
requires.
✔
✔
✔
✔
✔
Please release the information noted on Page 1 for the following purpose(s):
For a legal matter, including an administrative
hearing To see if I qualify for insurance coverage or benefits
For coordination of my care A Personal Request Other (note below):
Release and obtain personal information for statistical and billing purposes.
I permit DHHS to release and/or obtain my records as noted on this form. I understand and agree to the following:
•
This form will expire one year from the date I sign below, unless I revoke (take back) my permission sooner by
completing, signing and sending in the Revocation Form found on the DHHS website at
http://www.maine.gov/d
hhs/privacy/index.shtml. I may call DHHS at 207-287-3707 and ask for the office where
I receive services if I need help revoking this form.
•
I understand that taking back my permission to release my information does not apply to the information that
was already shared after I signed this form.
•
If I take back my permission to release my information, or if I refuse to release some or all of my healthcare or
insurance information, that may result in improper diagnosis or treatment, denial of insurance coverage or a
claim for health benefits, or other adverse consequences.
•
This form permits the people or offices listed on Page 1 to speak to each other for the purpose(s) on this form.
•
If I am disclosing healthcare information, I agree that records of any other providers (such as doctors, hospitals,
and counselors) in my file are included in this release.
•
Unless I am applying for benefits, DHHS will not condition my treatment, payment for services, or benefits
on whether I sign this form.
•
I have the right to make a written request to review my records. If I wish to receive a copy of my healthcare
or billing information, a fee may be charged as permitted by law.
•
If I want to review my mental health program or provider records before they are released, I must check
THIS BOX. D I understand that the review will be supervised.
•
DHHS offices will keep my information confidential as required by law. If I give my permission to share my
records with people who are not required by law to keep them private, they may no longer be protected by
federal confidentiality laws.
•
If alcohol or drug treatment or program records are included in this release, federal law requires the person
sharing those records to include a notice saying that such information may not be re-released or shared
without my written permission, unless required or permitted by law.
•
I am signing this form voluntarily, and I have the right to a signed copy of this form if I request one.
If requesting that electronic records be transmitted by email, please clearly print the email address below:
D I understand that DHHS systems may not be able to send my information securely through email. I understand that
email and the internet have risks that DHHS cannot control and that the information possibly could be read by a third
party. I accept those risks and still request that DHHS send my information by email. INITIAL HERE
Date: Signature
Personal Representative’s authority to sign:
DHHS Authorization Form 2/17
Page 2 of 2
✔
KENNEBEC BEHAVIORAL HEALTH
67 EUSTIS PARKWAY, WATERVILLE, ME 04901 - PHONE: (207) 873-2136 - FAX: (207) 680-4016
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
File / Send
Name: (first, middle initial, last)
ID: Date of Birth: Phone:
I hereby allow KBH, its approved staff or agents to release my Protected Health Information as outlined below.
(Check all
approved items)
Give, Get and Discuss Records and Information with: Get Records and Information From:
Give Records and Information To: Discuss Records and Information With:
Organization/Primary Contact:
Relationship: Service Provider or Case Manager Phone: Fax:
Address:
(A) The period for which information is requested is From: To:
(B) The specific information to be released is:
All information below
Discharge Summary
Lab Reports
Medications Treatment History
DSM Diagnosis (5 Axis)
Initial Evaluation/Assessment
Psychiatric Evaluation(s)
Psychological Assessment(s)/Testing
Medical Hx/Physical Treatment Plan(s)
Progress Notes
Other:
Housing and rental assistance tenant information.
(C) The reason for the release of this information is:
Assist with Evaluation/Assessment Treatment Planning Judicial Proceedings
Coordination of Services
Other:
To fulfill certification/recertification requirements for housing and/or subsidy assistance.
(D) If I have been diagnosed or treated for any of the following, I understand that my specific consent to disclose related information is
necessary. (Must pick an option for each of the three questions below.)
I Do Do Not
authorize disclosure of information which refers to treatment or diagnosis of drug or alcohol abuse.
Such information may not be re-disclosed by the recipient without my specific written consent.
I Do
I Do
Do Not
Do Not
authorize disclosure of information which refers to mental health/psychiatric treatment or diagnosis.
authorize disclosure of information that refers to treatment or diagnosis of HIV.
(E) I wish to look at the information before it is released. This review must be documented.
(F) I agree to the future release of information to the above person/organization during the approved time period.
(G) This agreement to release information has an
I understand that:
Expiration Date of: . This date can be no longer than 12 months.
•
I can take back this approval at anytime by making a request in writing to KBH Record Room or my service provider at KBH.
Stopping this Release of Information will not affect any information released before I took away my approval. Taking away my
approval to release records could result in improper diagnosis, improper treatment, and denial of insurance coverage or have other
negative consequences.
•
I can refuse to release some or all of my records. However, such refusals may result in improper diagnosis, improper treatment, and
denial of insurance coverage or have other negative consequences.
•
KBH cannot control people or organizations receiving this information to prevent re-release of it without my approval.
•
I can cross out any checked off item I do not agree with. I may have a copy of this form upon request.
SIGNATURE: DATE:
Client/Guardian or Other Authorized Person's Signature
WITNESS: DATE:
For Persons or Organizations receiving Substance Abuse or Mental Health Information:
This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR, Part
2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as
otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this
purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client (52 FR
21809: 52 FR 41997).
This information has been disclosed to you from records whose confidentiality is protected by State Confidentiality Laws (34 MRSA Section
1207; Rights of Recipients of Mental Health Services). This information remains confidential and should not be disclosed any further except
as expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by law.
To take back this approval, complete the revocation section below.
REVOCATION
I understand that it is my right to take back this authorization at anytime. I have been informed of the potential consequences resulting from
my taking back this authorization. I further understand that taking back this release will not affect the information already released as a result
of my original approval to do so but understand that all future releases of this information will not be allowed after the date below.
Revocation of Authorization: DATE: Client/Guardian or Other
Authorized Person's Signature
Witness Signature:
DATE:
KENNEBEC BEHAVIORAL HEALTH
67 EUSTIS PARKWAY, WATERVILLE, ME 04901 - PHONE: (207) 873-2136 - FAX: (207) 680-4016
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
File / Send
Name: (first, middle initial, last)
ID: Date of Birth: Phone:
I hereby allow KBH, its approved staff or agents to release my Protected Health Information as outlined below.
(Check all
approved items)
Give, Get and Discuss Records and Information with: Get Records and Information From:
Give Records and Information To: Discuss Records and Information With:
Organization/Primary Contact:
DHHS - Office of Substance Abuse and Mental Health Services
Relationship: Subsidy Provider Phone:
207-287-2595
Fax:
207-287-4334
Address:
41 Anthony Ave, 11 State House Station, Augusta, ME 04333-0011
(A) The period for which information is requested is From: To:
(B) The specific information to be released is:
All information below
Discharge Summary
Lab Reports
Medications Treatment History
DSM Diagnosis (5 Axis)
Initial Evaluation/Assessment
Psychiatric Evaluation(s)
Psychological Assessment(s)/Testing
Medical Hx/Physical Treatment Plan(s)
Progress Notes
Other:
Housing and rental assistance tenant information.
(C) The reason for the release of this information is:
Assist with Evaluation/Assessment Treatment Planning Judicial Proceedings
Coordination of Services
Other:
To fulfill certification/recertification requirements for housing and/or subsidy assistance.
(D) If I have been diagnosed or treated for any of the following, I understand that my specific consent to disclose related information is
necessary. (Must pick an option for each of the three questions below.)
I Do Do Not
authorize disclosure of information which refers to treatment or diagnosis of drug or alcohol abuse.
Such information may not be re-disclosed by the recipient without my specific written consent.
I Do
I Do
Do Not
Do Not
authorize disclosure of information which refers to mental health/psychiatric treatment or diagnosis.
authorize disclosure of information that refers to treatment or diagnosis of HIV.
(E) I wish to look at the information before it is released. This review must be documented.
(F) I agree to the future release of information to the above person/organization during the approved time period.
(G) This agreement to release information has an
I understand that:
Expiration Date of: . This date can be no longer than 12 months.
•
I can take back this approval at anytime by making a request in writing to KBH Record Room or my service provider at KBH.
Stopping this Release of Information will not affect any information released before I took away my approval. Taking away my
approval to release records could result in improper diagnosis, improper treatment, and denial of insurance coverage or have other
negative consequences.
•
I can refuse to release some or all of my records. However, such refusals may result in improper diagnosis, improper treatment, and
denial of insurance coverage or have other negative consequences.
•
KBH cannot control people or organizations receiving this information to prevent re-release of it without my approval.
•
I can cross out any checked off item I do not agree with. I may have a copy of this form upon request.
SIGNATURE: DATE:
Client/Guardian or Other Authorized Person's Signature
WITNESS: DATE:
To take back this approval, complete the revocation section below.
REVOCATION
I understand that it is my right to take back this authorization at anytime. I have been informed of the potential consequences resulting from
my taking back this authorization. I further understand that taking back this release will not affect the information already released as a result
of my original approval to do so but understand that all future releases of this information will not be allowed after the date below.
Revocation of Authorization: DATE: Client/Guardian or Other
Authorized Person's Signature
Witness Signature:
DATE:
KENNEBEC BEHAVIORAL HEALTH
67 EUSTIS PARKWAY, WATERVILLE, ME 04901 - PHONE: (207) 873-2136 - FAX: (207) 680-4016
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
File / Send
Name: (first, middle initial, last)
ID: Date of Birth: Phone:
I hereby allow KBH, its approved staff or agents to release my Protected Health Information as outlined below.
(Check all
approved items)
Give, Get and Discuss Records and Information with: Get Records and Information From:
Give Records and Information To: Discuss Records and Information With:
Organization/Primary Contact:
Shalom House
Relationship: Subsidy Provider Phone:
207-874-1080
Fax:
Address:
106 Gilman Street, Portland, ME 04102
(A) The period for which information is requested is From: To:
(B) The specific information to be released is:
All information below
Discharge Summary
Lab Reports
Medications Treatment History
DSM Diagnosis (5 Axis)
Initial Evaluation/Assessment
Psychiatric Evaluation(s)
Psychological Assessment(s)/Testing
Medical Hx/Physical Treatment Plan(s)
Progress Notes
Other:
Housing and rental assistance tenant information.
(C) The reason for the release of this information is:
Assist with Evaluation/Assessment Treatment Planning Judicial Proceedings
Coordination of Services
Other:
To fulfill certification/recertification requirements for housing and/or subsidy assistance.
(D) If I have been diagnosed or treated for any of the following, I understand that my specific consent to disclose related information is
necessary. (Must pick an option for each of the three questions below.)
I Do Do Not
authorize disclosure of information which refers to treatment or diagnosis of drug or alcohol abuse.
Such information may not be re-disclosed by the recipient without my specific written consent.
I Do
I Do
Do Not
Do Not
authorize disclosure of information which refers to mental health/psychiatric treatment or diagnosis.
authorize disclosure of information that refers to treatment or diagnosis of HIV.
(E) I wish to look at the information before it is released. This review must be documented.
(F) I agree to the future release of information to the above person/organization during the approved time period.
(G) This agreement to release information has an
I understand that:
Expiration Date of: . This date can be no longer than 12 months.
•
I can take back this approval at anytime by making a request in writing to KBH Record Room or my service provider at KBH.
Stopping this Release of Information will not affect any information released before I took away my approval. Taking away my
approval to release records could result in improper diagnosis, improper treatment, and denial of insurance coverage or have other
negative consequences.
•
I can refuse to release some or all of my records. However, such refusals may result in improper diagnosis, improper treatment, and
denial of insurance coverage or have other negative consequences.
•
KBH cannot control people or organizations receiving this information to prevent re-release of it without my approval.
•
I can cross out any checked off item I do not agree with. I may have a copy of this form upon request.
SIGNATURE: DATE:
Client/Guardian or Other Authorized Person's Signature
WITNESS: DATE:
To take back this approval, complete the revocation section below.
REVOCATION
I understand that it is my right to take back this authorization at anytime. I have been informed of the potential consequences resulting from
my taking back this authorization. I further understand that taking back this release will not affect the information already released as a result
of my original approval to do so but understand that all future releases of this information will not be allowed after the date below.
Revocation of Authorization: DATE: Client/Guardian or Other
Authorized Person's Signature
Witness Signature:
DATE:
KENNEBEC BEHAVIORAL HEALTH
67 EUSTIS PARKWAY, WATERVILLE, ME 04901 - PHONE: (207) 873-2136 - FAX: (207) 680-4016
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
File / Send
Name: (first, middle initial, last)
ID: Date of Birth: Phone:
I hereby allow KBH, its approved staff or agents to release my Protected Health Information as outlined below.
(Check all
approved items)
Give, Get and Discuss Records and Information with: Get Records and Information From:
Give Records and Information To: Discuss Records and Information With:
Organization/Primary Contact:
Relationship: Homeless Shelter
Phone:
Fax:
Address:
(A) The period for which information is requested is From: To:
(B) The specific information to be released is:
All information below
Discharge Summary
Lab Reports
Medications Treatment History
DSM Diagnosis (5 Axis)
Initial Evaluation/Assessment
Psychiatric Evaluation(s)
Psychological Assessment(s)/Testing
Medical Hx/Physical Treatment Plan(s)
Progress Notes
Other:
Housing and rental assistance tenant information.
(C) The reason for the release of this information is:
Assist with Evaluation/Assessment Treatment Planning Judicial Proceedings
Coordination of Services
Other:
To fulfill certification/recertification requirements for housing and/or subsidy assistance.
(D) If I have been diagnosed or treated for any of the following, I understand that my specific consent to disclose related information is
necessary. (Must pick an option for each of the three questions below.)
I Do Do Not
authorize disclosure of information which refers to treatment or diagnosis of drug or alcohol abuse.
Such information may not be re-disclosed by the recipient without my specific written consent.
I Do
I Do
Do Not
Do Not
authorize disclosure of information which refers to mental health/psychiatric treatment or diagnosis.
authorize disclosure of information that refers to treatment or diagnosis of HIV.
(E) I wish to look at the information before it is released. This review must be documented.
(F) I agree to the future release of information to the above person/organization during the approved time period.
(G) This agreement to release information has an
I understand that:
Expiration Date of: . This date can be no longer than 12 months.
•
I can take back this approval at anytime by making a request in writing to KBH Record Room or my service provider at KBH.
Stopping this Release of Information will not affect any information released before I took away my approval. Taking away my
approval to release records could result in improper diagnosis, improper treatment, and denial of insurance coverage or have other
negative consequences.
•
I can refuse to release some or all of my records. However, such refusals may result in improper diagnosis, improper treatment, and
denial of insurance coverage or have other negative consequences.
•
KBH cannot control people or organizations receiving this information to prevent re-release of it without my approval.
•
I can cross out any checked off item I do not agree with. I may have a copy of this form upon request.
SIGNATURE: DATE:
Client/Guardian or Other Authorized Person's Signature
WITNESS: DATE:
To take back this approval, complete the revocation section below.
REVOCATION
I understand that it is my right to take back this authorization at anytime. I have been informed of the potential consequences resulting from
my taking back this authorization. I further understand that taking back this release will not affect the information already released as a result
of my original approval to do so but understand that all future releases of this information will not be allowed after the date below.
Revocation of Authorization: DATE: Client/Guardian or Other
Authorized Person's Signature
Witness Signature:
DATE:
KENNEBEC BEHAVIORAL HEALTH
67 EUSTIS PARKWAY, WATERVILLE, ME 04901 - PHONE: (207) 873-2136 - FAX: (207) 680-4016
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
File / Send
Name: (first, middle initial, last)
ID: Date of Birth: Phone:
I hereby allow KBH, its approved staff or agents to release my Protected Health Information as outlined below.
(Check all
approved items)
Give, Get and Discuss Records and Information with: Get Records and Information From:
Give Records and Information To: Discuss Records and Information With:
Organization/Primary Contact:
Relationship: Phone:
Fax:
Address:
(A) The period for which information is requested is From: To:
(B) The specific information to be released is:
All information below
Discharge Summary
Lab Reports
Medications Treatment History
DSM Diagnosis (5 Axis)
Initial Evaluation/Assessment
Psychiatric Evaluation(s)
Psychological Assessment(s)/Testing
Medical Hx/Physical Treatment Plan(s)
Progress Notes
Other:
Housing and rental assistance tenant information.
(C) The reason for the release of this information is:
Assist with Evaluation/Assessment Treatment Planning Judicial Proceedings
Coordination of Services
Other:
To fulfill certification/recertification requirements for housing and/or subsidy assistance.
(D) If I have been diagnosed or treated for any of the following, I understand that my specific consent to disclose related information is
necessary. (Must pick an option for each of the three questions below.)
I Do Do Not
authorize disclosure of information which refers to treatment or diagnosis of drug or alcohol abuse.
Such information may not be re-disclosed by the recipient without my specific written consent.
I Do
I Do
Do Not
Do Not
authorize disclosure of information which refers to mental health/psychiatric treatment or diagnosis.
authorize disclosure of information that refers to treatment or diagnosis of HIV.
(E) I wish to look at the information before it is released. This review must be documented.
(F) I agree to the future release of information to the above person/organization during the approved time period.
(G) This agreement to release information has an
I understand that:
Expiration Date of: . This date can be no longer than 12 months.
•
I can take back this approval at anytime by making a request in writing to KBH Record Room or my service provider at KBH.
Stopping this Release of Information will not affect any information released before I took away my approval. Taking away my
approval to release records could result in improper diagnosis, improper treatment, and denial of insurance coverage or have other
negative consequences.
•
I can refuse to release some or all of my records. However, such refusals may result in improper diagnosis, improper treatment, and
denial of insurance coverage or have other negative consequences.
•
KBH cannot control people or organizations receiving this information to prevent re-release of it without my approval.
•
I can cross out any checked off item I do not agree with. I may have a copy of this form upon request.
SIGNATURE: DATE:
Client/Guardian or Other Authorized Person's Signature
WITNESS: DATE:
To take back this approval, complete the revocation section below.
REVOCATION
I understand that it is my right to take back this authorization at anytime. I have been informed of the potential consequences resulting from
my taking back this authorization. I further understand that taking back this release will not affect the information already released as a result
of my original approval to do so but understand that all future releases of this information will not be allowed after the date below.
Revocation of Authorization: DATE: Client/Guardian or Other
Authorized Person's Signature
Witness Signature:
DATE:
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BRAP Application - 04 17 2018 (2)

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Completed 15 July 2020

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