Patient Forms

Organizational Forms

Forms Description
Consent to Services Form Required form that gives the organization permission to coordinate services on your behalf
Authorization of Release and Exchange of Information Required form that designates the organization we can send and receive information from on your behalf. A form is required for each designated organization.
Client Grievance Procedure Required from that states you have read and understood the organizations grievance process
Notice of Privacy Practice Document that explains how the organization uses the medical information we collect from you.
Privacy Practices Attestation Required form that states you have read and understand the Notice of Privacy Practice.
No Insurance Statement Form that attests that client does not have health insurance.
Zero Income Statement Form that attests that client as no sources of income.
Eligibility Continuation Form Required form that must be completed every 6 months to remain eligible for services with the organization.
External Referral Form Used to make referrals to services housed within Heart to Hand, Inc.

Application for Services

Forms Description
GBMS Dental Application Application for dental services at Greater Baden Medical Services for HIV positive persons.
STRMU Application Short Term Rental, Mortgage, and Utility assistance for HIV positive persons
Maryland AIDS Drug Assistance Program (MADAP) Pharmaceutical assistance for HIV positive persons
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