AIP - Brenner Intake Packet

PHYSICIAN AND DISABILITY INFORMATION

This information is to ensure safe transportation and in case of an emergency
Physician Name*

First NameLast Name
Physician Phone Number*
Please enter a valid phone number.
Physician Fax Number
Please enter a valid phone number.
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Email Address
example@example.com
Reason you require escorted transportation:
Expected duration of disability:
What type of equipment do you use? (Select all that apply)*

CaneWalkerSeated WalkerWheelchairElectric WheelchairNone
Do you require an additional escort?*

YesNo
Reason:*
By signing this application,I am confirming that I understand that the information provided will be kept confidential, and that it is only used to determine my eligibility to participate in the Brenner Escorted Transportation Program (the “Program”). I certify that all information contained on this form is true and correct. I give my permission for the Jewish Social Service Agency (“JSSA”) to obtain eligibility information from my doctor, social worker, or other healthcare provider. I agree to pay all fees associated with the Program. I voluntarily assume the risks associated with receiving transportation services from the Program andJSSA and recognize that neither the Program nor JSSA is a common carrier. I fully release the Program, JSSA, JSSA’s affiliates, and JSSA’s officers, directors, employees, agents, and volunteers and hold them harmless for any and all claims, including, but not limited to injury, harm, damages, or loss arising out of, connected with, or in any way associated with use of the services provided by the Program.
Client Signature or Authorized Representative*

Clear
Date*

MonthDayYear
Date

BRENNER ESCORTED TRANSPORTATION PASSENGER CODE OF CONDUCT AND RIDE CANCELLATION POLICY
Please take a moment to review the Brenner Escorted Transportation Passenger Code of Conduct and Ride Cancellation Policy below. You can print a copy of the document by clicking the print icon at the top right of the window or you may hit the arrow button and download a copy to your computer.
Tómese un momento para revisar el Código de conducta para pasajeros y la Política de cancelación de viajes de transporte acompañado de Brenner a continuación. Puede imprimir una copia del documento haciendo clic en el ícono de impresión en la parte superior derecha de la ventana o puede presionar el botón de flecha y descargar una copia a su computadora.
Brenner Escorted Transportation Passenger Code of Conduct and Ride Cancellation Policy*

I have received, reviewed, understand and agree to abide by the Brenner Escorted Transportation Passenger Code of Conduct and Ride Cancellation Policy
Client or Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date

FEE AGREEMENT
Please take a moment to review the Fee Agreement below. You can print a copy of the document by clicking the print icon at the top right of the window or you may hit the arrow button and download a copy to your computer.
Tómese un momento para revisar la Lista de Tarifas de JSSA. Puede imprimir una copia del documento haciendo clic en el icono de impresión en la parte superior derecha de la ventana o puede presionar el botón de flecha y descargar una copia a su computadora.
FEE AGREEMENT*

I agree to be financially responsible for the assessed program fees. I understand that failure to make payment may result in termination of services.dora.
Signature*

Clear
Date*

MonthDayYear
Date

CLIENT RIGHTS AND RESPONSIBILITIES
Please take a moment to review the Client Rights and Responsibilities below. You can print a copy of the document by clicking the print icon at the top right of the window or you may hit the arrow button and download a copy to your computer.
Tomese un momento para revisar los Derechos y Responsabilidades del Cliente a continuacion. Puede imprimir una copia del documento haciendo clic en el icono de impresion en la parte superior derecha de la ventana o puede presionar el boton de flecha y descargar una copia a su computadora.
Consent to Abide by JSSA's Client Consent and Acknowledgement, Grievance Procedure, and Consent to Treatment*

I have been oriented to services and acknowledge that I have been given ample opportunity to ask questions that I have concerning my care and services at JSSA. I acknowledge that I have been provided with a copy of my rights and responsibilities as a client. Additionally, I have been informed of all relevant facts, risks and benefits, obligations, and available alternatives to the services I will be receiving at JSSA.
I have received, reviewed, understand and agree to abide by JSSA's statement of Client Consent and Acknowledgements and Grievance Procedure and the information therein, and provide my consent to treatment/services. I understand that I may withdraw my consent at any time for any reason.
I have signed this consent and acknowledgement of my own free will without fear of penalty or loss of service.
Signature of Client or Legal Representative*

Clear
Date*

MonthDayYear
Date
Name of Authorized Representative if not the Client

First NameLast Name
*If you are signing as a legal representative of the individual (e.g., court ordered guardianship, power of attorney, healthcare proxy, etc.), you must provide proof of your legal authority to act for this individual or this authorization will be denied. At the end of this packet, you will be given an opportunity to upload a copy of this authority.

Acknowledgement of Receipt of Notice of Privacy Practices
Please take a moment to review the Notice of Privacy Practices below. You can print a copy of the document by clicking the print icon at the top right of the window or you may hit the arrow button and download a copy to your computer.
Tómese un momento para revisar el Aviso de Prácticas de Privacidad a continuación. Puede imprimir una copia del documento haciendo clic en el icono de impresión en la parte superior derecha de la ventana o puede presionar el botón de flecha y descargar una copia a su computadora.
Acknowledgement of Receipt of Notice of Privacy Practices*

I understand that the privacy practices and policies described in this document do not fully describe JSSA's Privacy Practices, and I acknowledge that a full description of JSSA's privacy practices can be found only in JSSA's Notice of Privacy Practices.
I also hereby acknowledge that I have received a copy of JSSA's Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact JSSA's Privacy Officer at 301-610-8303.
Signature of Client or Legal Representative*

Clear
Date*

MonthDayYear
Date
Name Authorized Representative if not the Client

First NameLast Name
*If you are signing as a legal representative of the individual (e.g., court ordered guardianship, power of attorney, healthcare proxy, etc.), you must provide proof of your legal authority to act for this individual or this authorization will be denied. At the end of this packet, you will be given an opportunity to upload a copy of this authority.
Consent to Receive Communications by Selected Communication Preferences
In accordance with all applicable laws, JSSA will communicate with you using your stated communication preference. These preferences will only apply to communications between JSSA and yourself. If you wish JSSA to communicate with other individuals, you must complete a separate written authorization for JSSA to do so. If you need written information in another format (larger print, audio, etc.), or an interpreter or written communication is needed in a language other than English, please let a JSSA workforce member know. These services will be free of charge.
Please discuss these communication options with your JSSA workforce member(s). Additionally, JSSA's workforce member can provide you with written instructions on how to access secure email communications.
I prefer to receive Appointment Reminders ONLY via (only check one):*

Text MessageEmail
When appropriate, I prefer to receive service-related communications via:*

Cell PhoneHome PhoneSecure Email
Consent to Receive Communications Attestation*

I have discussed my options for receiving service-related communication from JSSA with a JSSA workforce member, and I hereby authorize JSSA to communicate with me in accordance with my communication preference indicated above.
Signature of Client or Legal Representative*

Clear
Date*

MonthDayYear
Date
Name of Authorized Representative if not the client*

First NameLast Name
*If you are signing as a legal representative of the individual (e.g., court ordered guardianship, power of attorney, healthcare proxy, etc.), you must provide proof of your legal authority to act for this individual or this authorization will be denied. At the end of this packet, you will be given an opportunity to upload a copy of this authority.
Upload a copy of your proof of legal authority (ex: Power of Attorney):

Cancelof

CLIENT INFORMATION

CLIENT CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

PHYSICIAN AND DISABILITY INFORMATION

BRENNER ESCORTED TRANSPORTATION PASSENGER CODE OF CONDUCT AND RIDE CANCELLATION POLICY

FEE AGREEMENT

CLIENT RIGHTS AND RESPONSIBILITIES

Acknowledgement of Receipt of Notice of Privacy Practices

Consent to Receive Communications by Selected Communication Preferences

DEMOGRAPHIC QUESTIONNAIRE