Ice Bucket Challenge Progress

 

If you're a person with ALS or you care for one, we're here to help. We'll connect you with the local resources you need, including equipment loans, counseling, grants to help with ALS-related expenses, and access to ALS clinics and clinical trials. Register today and a St. Louis Regional Chapter Care Services Coordinator will contact you to address your needs.

 

 

New Patient Registration

  Patient Information:

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Name:

 

 

 

 

 

         

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City/State/ZIP:

 

    

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Date of Birth:

 

If you respond and have not already registered, you will receive periodic updates and communications from The ALS Association Saint Louis Chapter.

 

What's this?

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Question - Required - Please select the racial category with which you most closely identify.










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Question - Required - Marital Status:

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Question - Required - What is your average household income? This information is gathered for United Way statistical reporting purposes only. It does not affect your ability to receive chapter services.








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Question - Required - How did you hear about us?

 

(Maximum response 255 chars, approx. 5 rows of text)

 

Caregiver Information:

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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Caregiver's Race:










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Question - Required - Caregiver's Date of Birth:




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Diagnosis and Physician Information:

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Question - Required - Date of diagnosis:




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Question - Required - Type of onset:


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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Assistive Devices (please mark all devices that you are currently using):

 

 

Consent and Release- Care Services and Equipment

There are four (4) basic purposes of this form:

 

  1. To permit the chapter to provide services, programs, and/or equipment without concern of legal action against the Chapter or its personnel

  2. To permit the Chapter to release and obtain your medical information to your practitioners so it can serve you properly

  3. To permit the Chapter to communicate with your care team members

  4. To authorize the chapter to utilize any photos taken during Chapter events and/or clinic settings to use for marketing efforts

 

The chapter follows all the guidelines set under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). This consent and release is valid until date withdrawn by patient and/or his or her agent, or when the patient file is closed by the Chapter representative.


The Amyotrophic Lateral Sclerosis Association St. Louis Regional Chapter ("Chapter") is an organization dedicated to the discovery of the cause of ALS through research while providing patient support, information and education, and, as such, has been determined by the Internal Revenue Service to be a tax exempt organization; and


The following individual is a patient with ALS ("Patient") who anticipates receiving, and/or has received, from or through the auspices of the Chapter, services and/or the use of equipment designed to help Patient deal more effectively and/or comfortably with ALS: and


The available services provided by the Chapter include, among other things, in-home care; wheelchair accessible van transportation; supportive therapies; equipment loan and/or maintenance - medical and communication; family counseling; nursing home care; nutrition support ("Services")

 

In consideration of the above and intending to be legally bound hereby, and being authorized and competent to do so, Patient, and/or his or her representative, on behalf of Patient, Patient's family, and caretaker of Patient, and their heirs, representatives and assigns (each hereinafter called "Releasors"), does sign this Consent and Release in favor of Chapter, its Directors, officers, employers, volunteers, agent and their heirs, representatives, and assigns (each hereinafter called "Releasees"), and does agree as follow:

 

  1. Releasors, being duly authorized and competent to do so, release and discharge all of the Releasees, from all claims, liability, causes of action, and judgments, past, present, and future, known or unknown at the time of signing of this Consent and Release, particularly arising from Services or equipment available to Patient, or Patient's family, or to any of the Releasors, by or through the auspices of the Chapter

  2. Releasors, being duly authorized and competent to do so, consent to and fully permit the use, receipt, release and communication of all medical and health information concerning Patient to or from health insurance companies and medical or medically related entities and/or individuals and health care providers, such as health companies, for all purposes consistent with all available services with which the Chapter is involved, whether or not listed above

  3. Releasors acknowledge that they may, from time to time, receive from the Chapter solicitations, informational mailings, newsletters, and/or announcements of events. Upon receipt from Releasor(s) of a written request, the Chapter shall refrain from sending Releasor(s) any or all such mailings

  4. Releasors agree that a photocopy and/or facsimile copy of this Consent and Release may be relied upon in the same manner as the original

  5. Patient and related Releasors further state that they have read this Consent and Release, that they understand and agree to its contents, and that they have been given the opportunity, although not required, and if desired by Patient, to review it with their attorney prior to signing it, at their own discretion

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HIPAA Patient Family Consent Form

The ALS Association is not a covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), however the chapter follows the guidelines set forth by this legislation due to the sensitivity of an ALS diagnosis. This consent and release is valid until the date withdrawn by the patient (or his/her agent) or when the patient file is closed by the chapter representative. The primary purpose of this form will be for the enrollment of programs and services offered by the chapter.

 

The rules of HIPAA cover PHI (Protected Health Information) which includes but is not limited to the person's physical/mental health condition currently, in the past or in the future, and any identifying information such as name, date of birth, Social Security and address. It also addresses electronic transmission/discussion of PHI.

 

Under HIPAA Privacy Rule, if an individual (patient or his/her agent) initiates communication with the provider through electronic means, the provider can assume that the electronic communications are acceptable to the individual.

 

Chapter Confidentiality Policies


  • The chapter will not hold any discussions regarding PHI or ALS diagnosis related information electronically, including email or text message without permission from the patient family

  • Some services and programs provided by the Chapter include volunteers and contract providers. Signing this form indicates that PHI can be disclosed to those community partners necessary for the access to and provision of these services and programs

  • If the patient is treated at an ALS Association sponsored Clinic or Center of Excellence, it is not necessary to list those multidisciplinary team members because a representative of the Chapter works directly as a part of the health care team and this is addressed at a form signed at that entity

  • Health information of patients, caregivers, or family members under the age of 18, will not be released without written authorization from the patient family addressing specifically to whom. Released information must be written and the form must be signed and dated by patient or the patient's durable power of attorney for health care

 

Patient Care Team

To allow the Chapter to operate in accordance with HIPPA, the patient must designate those members of his/her care team with whom PHI can be discussed.

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