Patient Forms
Save time during your visit by completing your forms in advance. Access and download essential patient documents here to streamline your check-in process and ensure a seamless experience.
Forms for Accessing Care at Heart to Hand
Consent to Services Form
Required form that gives Heart to Hand permission to coordinate services on your behalf
Authorization of Release and Exchange of Information
Required form that designates Heart to Hand can send and receive information on your behalf. A form is required for each designated organization
Client Grievance Procedure
Required form that states you have read and understood the organizations grievance process
No Insurance Statement
Form that attests that client does not have health insurance
Privacy Practices Attestation
Required form that states you have read and understand the Notice of Privacy Practice
Zero Income Statement
Form that attests that client as no source of income
Consent to Care Ware Eligbility Form
Form that allows clients to consent or decline sharing your eligibility and health information with other Ryan White providers in the DC CAREWare system.
Eligibility Continuation Form
Required form that must be completed every six months to remain eligible for services with Heart to Hand.
Inbound Referral Form
Form used to make referrals to services housed within Heart to Hand.
Case Management Rights and Responsibilities Form
Form that explains clients’ rights and responsibilities while receiving case management services at Heart to Hand.
Inclusive form
This form confirms Heart to Hand’s commitment to inclusion and non-discrimination.
Transportation form
This form explains Heart to Hand’s transportation policy and how clients can access transport services.