Apply for Membership

The purpose of The Kindness Initiative is to assist Jewish households experiencing adverse economic circumstances. Program services include but are not limited to assessing needs, recommending community-based organizations and other sources that may be appropriate to meeting those needs, and providing assistance whenever possible to help navigate requirements of referral agencies. The Kindness Initiative does not guarantee successful outcomes or the ability to serve all clients who seek assistance.

Part 1: Application Information:

Part 2: Consent for Assistance

CONSENT FOR ASSISTANCE
I consent and agree voluntarily to receive services from The Kindness Initiative (KI) or its Services Provider Partners (SPP). These services may include, but are not limited to or guaranteed to include: providing information on available services; funding or planning resources; providing volunteer advocates to assist in navigating and accessing services and obtaining government benefits; financial aid for rent, emergencies, life cycle events and other select needs; information on food sources; housing; obtaining basic household goods; transportation; employment assistance; home and auto repairs; health and wellness resources such as medical services, dentistry, medications; vision care, auditory services, mental health and physical disabilities resources; “wrap-around,” case management services; legal services; taxation and accounting services; substance abuse and domestic violence counselling; as well as social interactions programs for the elderly and childcare options.

Please initial each item below to acknowledge you have read and understood the terms.

I understand that by consenting to assistance, personal health and other information may be exchanged in a limited way for services, payment and operations purposes, only.I understand that I have the right to terminate assistance at any time. I also understand that I have the right to refuse to implement any recommendations.I understand that I am expected to benefit from assistance, but there is no implied or expressed guarantee that I will.I understand that KI is an administrative non-profit organization and responses to Members’ inquiries may be delayed when the office is closed at night, holidays and weekends. I understand that in the event of an emergency, I will call 911.I understand and request to participate in telecare counseling services provided by both KI and SPPs.

IN-PERSON SERVICES

You have requested to receive services from KI and our SSPs, and we are proud to be able to offer these services. In making this request and in signing below, you agree to abide by all KI safety and service protocols. Further, you agree to do the following:

• Bring an appropriate mask/face shield to each meeting with KI or SPP staff or volunteers;

• Adhere to all safety precautions, including 6’ social distancing, frequent use of sanitation items, and not entering the office or meet KI or SPP staff or volunteers, if you, a person accompanying you, or anyone with whom you spent the 24 hours immediately prior to your appointment are showing any signs or symptoms of exposure to COVID-19;

• Abide by the decisions of KI staff and volunteers related to access to the KI and SPP offices;

• Provide truthful and accurate information related to your needs, health and safety questions; and

• To stay home if you or a person accompanying you feels ill. Note: You can complete your services discussion via telephone.

By agreeing below, you agree to work constructively with KI and SPP personnel, and you agree to abide by all stated and/or posted guidelines.

AgreeDo not Agree

Part 3: Authorization to Disclose, Exchange or Obtain Information

Purpose: The purpose of this disclosure of information is to improve assessment and assistance planning, share information relevant to assistance and when appropriate, coordinate assistance services.

Excluded Organizations which are not authorized for release of information:

Form of Disclosure: The Kindness Initiative reserves the right to disclose information as permitted by this authorization in any manner it deems to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

RIGHTS

I understand my records are protected under federal regulations and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I can refuse to sign this authorization. I understand that I may inspect or obtain a copy of the information used or disclosed, as provided in 45 Code of Federal Regulations section 164.524. I understand that I have the right to revoke this authorization at any time. I understand that the revocation will not apply to information that has already been released based on this authorization. Any revocation or modification of this authorization must be in writing and received by The Kindness Initiative at 4950 Murphy Canyon Rd., San Diego, CA92123.

OR

For online submission:

By accepting below, you agree to the above Authorization to Disclose, Exchange or Obtain Information Statement

AcceptDo not Accept

By sending or submitting this form - I acknowledge that the above information is true and correct and that my signature is valid. I also acknowledge that I have the right to revoke this authorization in writing at any time. Any revocation or modification of this authorization must be in writing and received by The Kindness Initiative at 4950 Murphy Canyon Rd., San Diego, CA 92123. . I further understand that I will be given a copy of this authorization for my records.

Part 4: Privacy Policy

NOTICE OF PRIVACY PRACTICES SUMMARY NOTICE

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Kindness Initiative (KI) may keep medical information about you. This information is personal and private. We may need to use this information in several ways:

• Conduct, plan and direct your assessment, which may be reviewed at agency meetings.

• Obtain payment from third-party payers.

• Conduct normal operations such as determining appropriate services by KI or Service Provider Partners.

Under the Health Insurance Portability & Accountability act of 1996 (HIPAA). I have certain rights to privacy regarding my protected health information (PHI). These rights are:

• Review the complete notice of privacy practices to signing this agreement.

• Right of access to inspect and copy information in my file.

• Right to amend information in my file.

• Right to an accounting of disclosures made about information in my file.

• Right to request restrictions on how my information is used. I understand KI is not required to agree to my request.

• Right to request the way in which information about me is shared.

• Right to copy of this notice.

• The right to file a complaint regarding privacy with the Secretary of Health and Human Services toll free at 877-696-6775. If I have any questions regarding my privacy rights I can contact KI privacy official at 858.216.1666.

Release of Liability

I accept the terms and conditions set forth by the Release of Liability above