Assess My Needs

I hereby authorize the use or disclosure of my protected health information by the State of Nevada, Department of Health and Human Services, as described below. I understand the following:
1. The purpose of this disclosure is for the Aging and Disability Services Division (ADSD) and their network partners to assist me in obtaining services. They may share the information I have provided in this webform with any social service agency that may provide me service such as housing, meals, healthcare, and counseling services.
2. The information I provided in this webform may be redisclosed and no longer protected by federal privacy regulations.
3. I may inspect or copy the information used or disclosed.
4. This authorization is voluntary, and I may revoke this authorization at any time by notifying ADSD in writing. This authorization expires when I no longer seek services from ADSD.

Information about the individual completing this form:

Please enter the information for the person who is in need of assistance:

Living Situation & Income

Insurance Coverage

Resources & Assistance

Mental & Behavioral Health

Additional Information

Authorization for the Use and Disclosure of Protected Health Information

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