Case Management Consent Form

Last modified: August 6th, 2024

 

CONSENT FOR PARTICIPATION
IN CASE MANAGEMENT & RELEASE OF MEDICAL INFORMATION
I, as a patient of Blossom Q Health Inc. (D/b/a Equal Health), hereby agree and acknowledge my choice to participate in case management services provided by the Trans Housing Coalition (“THC”) in conjunction with treatment of gender affirming care and/or HIV prevention care.
I understand this means:

1. My case manager may contact me and/or my provider to discuss my healthcare needs.
2. By my signature below, I authorize the release of medical information by my case manager to Equal Health and release of relevant information from Equal Health to my case manager. This information will be used to create, update, and review any treatment plan that may be recommended by my provider.
3. Case management services are provided by THC and are independent of any medical care received by Equal Health.
4. It’s my choice to participate.
5. Some benefits provided by THC in conjunction with Equal Health will require case management. I understand if I choose to decline case management services, I may become ineligible to participate in THC facilitated treatment and care.

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