Release of Information

Consent for Reach for Independence to exchange information with DSS, Partners, VayaHealth, and potential staff strictly in regards to setting up services.

This field is for validation purposes and should be left unchanged.
Member Name:(Required)
Terms and Conditions(Required)
**Electronic Signature Attestation**(Required)
**Electronic Signature Attestation** By signing below, I certify that I am the individual listed above or the legally authorized representative of the individual, and that I have the authority to provide this authorization. I understand and agree that my electronic signature is the legal equivalent of my handwritten signature and that it is made in compliance with applicable federal and state laws, including the Electronic Signatures in Global and National Commerce (E-SIGN) Act and the Uniform Electronic Transactions Act (UETA). I further attest that the information provided is true and correct to the best of my knowledge.

Privacy, Confidentiality & HIPAA Compliance

At Reach for Independence, Inc., protecting the privacy and confidentiality of the individuals and families we serve is a top priority. We are committed to maintaining the highest standards of security and compliance in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our Commitment to Privacy

We understand that personal, medical, and service-related information is sensitive. Reach for Independence, Inc. takes all necessary steps to ensure that:

  • Information is kept confidential and secure
  • Access is limited to authorized personnel only
  • Information is used solely for service coordination and support
  • All staff are trained on HIPAA and confidentiality requirements

How Information May Be Used

Client information is only used and shared when necessary to:

  • Coordinate and establish services
  • Communicate with care managers and funding sources
  • Ensure appropriate care and support planning
  • Meet legal and regulatory requirements

We do not share information unnecessarily and only disclose the minimum information required for the intended purpose.

Who We May Share Information With

When necessary and authorized, information may be shared with:

  • Government agencies such as the Department of Social Services (DSS)
  • Managed care organizations such as Vaya Health
  • Partner providers and agencies involved in care
  • Qualified staff or contractors for the purpose of service delivery

All disclosures are made in accordance with applicable privacy laws and only with proper authorization.

Your Rights

Clients and their guardians have the right to:

  • Request access to their records
  • Request corrections to inaccurate information
  • Revoke consent for information sharing (in writing)
  • Ask questions about how their information is used

Authorization for Release of Information

To coordinate services effectively, we require written permission to share and obtain necessary information.

This authorization:

  • Is used only for the purpose of establishing and coordinating services
  • Limits who we communicate with
  • Expires after 365 days
  • Can be revoked at any time in writing

Questions or Concerns

If you have any questions about privacy, confidentiality, or how your information is handled, please contact us:

Reach for Independence, Inc.
(828)654-0901
HR@reachforindependence.com

We are committed to earning and maintaining your trust by protecting your information with integrity, respect, and care.