Referral

**At time of referral, we ask that you submit the individuals Face Sheet, CSSP, MNChoice and any other supporting documents (if you have them available) for review

Applicant’s Name

Clients with support or emotional support animals will need to request a reasonable accommodation and provide supporting documentation to support the request.

Upload your files
Please upload the following documents to support your application. Each of these documents are required upon acceptance into Mn Corporate Housing’s programs. If you do not add it now, you will be able to add it later but this will delay your application in being processed. There will be an authorization to release information form to sign on the next page

Declaration           By signing below, I certify that the information included in this form is correct to the best of my knowledge. 

Name of person completing this form

This completes the Referral Housing Application. The next step is to sign the release of information so that we can begin to process your application. Release of Information Authorization Please read and sign the following so that we can begin to process your application.

I have reviewed the Notice of Use and Disclosure Practices. I understand that the requested Protected Health Information, criminal background information, and rental history will be used by American Home Health Care for the purpose of American Home Health Care. I hereby authorize verbal and written communication from American Home Health Care and in addition, agree to release: The following portions of my clinical record: History and Physical Discharge Summary

Consults Plans of Care Current/ Past Progress Notes Mental Health Records Chemical Dependency Records Operative Reports Health Care Directives Medication List (including Pharmacy Communication) Physician’s Orders Flow Sheets POLST (Health Care Directive) Laboratory Results (All) Radiology Reports (All)   And the following portions of other records to Affinity Residential including: Criminal Background Check via BCA or other sources Rental History Verifications within the last 5 years Case Management Records   Please read through the declaration below and sign and date at the bottom. I understand that the records will be used to continue evaluation or treatment, coordinate services, and determine eligibility for services. I understand that my records are protected by data privacy regulations. Alcohol and drug abuse records may be protected by Federal Law (42 CFR Part 2). These records cannot be released without my consent unless specifically directed by law.   I understand that I have the right to refuse to sign this consent.   I understand that I may withdraw or revoke this consent at any time if the action it authorizes has not been carried out.   I understand that this consent expires one year from the date I signed it.   A copy of this authorization shall be considered as effective and valid as the original.

Check each box that applies