R2R Mental Health Grant Intake Form

Please complete this form to the best of your ability, the more detailed you can be the better. All personal information provided is private protected information and will not be shared with any outside source. The provided information regarding your medical history and wellbeing will be used to provide medical care only and is private.

Road 2 Recovery Foundation Mental Health Grant Intake Form

Step 1 of 2 - Authorization to Release and Disclose Patient Information The Road 2 Recovery Foundation

1. Authorization to Release and Disclose Patient Information to The Road 2 Recovery Foundation
THIS IS A RELEASE AND CONSENT TO USE PERSONAL INFORMATION FOR MEDICAL PURPOSES ONLY.
A. Patient Information
Date
MM slash DD slash YYYY
Patient Name*
First Last
Phone*
B. Authorization of Release of Protected Health Information
I hereby authorize The Road 2 Recovery Foundation full access; use and disclose my complete health record, including records relating to any mental healthcare, communicable diseases (e.g. HIV or AIDS) and treatment of alcohol or drug abuse, health information in compliance with state and federal law. This authorization shall be in force and effect for one year, unless I specify a different expiration here, in which case this authorization expires upon the occurrence of that event or date.*
- Check this box to authorize
Alternative Expiration:
Signature*

By typing your name you are certifying this is a legal signature.
Date
MM slash DD slash YYYY
C. Revocation
I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation shall not be effective to the extent that any person or entity has already acted in reliance on my authorization.*
- Check this box to authorize
D. Not Restriction on Treatment
I understand that my ability to obtain treatment will not be conditioned on whether I sign this authorization.*
- Check this box to authorize
E. Further Disclosures
I understand and acknowledge that Road 2 Recovery Foundation may re-disclose my protected health information described above in accordance with state and federal law and that Road 2 Recovery Foundation cannot prevent re-disclosure of my protected health information described above by the person or organization who may receive my protected health information from Road 2 Recovery Foundation. By signing this authorization, I release Road 2 Recovery Foundation from any and all liability resulting from a re-disclosure by the recipient. I understand and acknowledge that my signature indicates that I have read and understand this form, and authorize release of my protected health information as described above.*
- Check this box to authorize
F. Road 2 Recovery Hold Back

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2. PATIENT'S PERSONAL INFORMATION
For good and valuable consideration, the receipt of which is hereby acknowledged, I, the undersigned, do hereby agree as follows:

1. USE OF PERSONAL INFORMATION. I hereby grant to Road 2 Recovery Foundation, an Arizona non-profit corporation, and its affiliates and assigns (“R2R”), the perpetual right and permission to use, exploit, adapt, modify, reproduce, distribute, publicly perform, and display my name, likeness, image, voice, recorded voice, appearance, biographical information, statements, performance, testimonials, and/or information related to support I have received from R2R, including, without limitation, the amount of money received from R2R, the nature and cost of items donated to me (whether in goods or services) through R2R and the type and location of rehabilitation services I have received through R2R (collectively “Personal Information”), throughout the world, in any manner and in any form or media now known or later developed, for the purpose of advertising, promoting, publicizing and otherwise providing information about R2R’s services, without review or compensation. R2R shall own any recording, product, publication, presentation, copy, or any other material it creates, or that is created on its behalf, containing or featuring my Personal Information (the “Works”), including all copyright rights therein. I understand and acknowledge that I have no interest or ownership rights in the Works (or any portion thereof) or their copyrights.

2. NO OBLIGATION. I understand that R2R has the right, but not the obligation, to use my Personal Information. I understand further that R2R may use, or not, in its sole discretion, some or all of my Personal Information, whether alone or in conjunction with any other material of any kind or nature, except that R2R will not use my Personal Information for any criminal or illegal purposes or in a manner inconsistent with community standards of decency.

3. RELEASE AND INDEMNIFICATION. I hereby release and agree to indemnify, defend and hold harmless R2R, its agents, employees and licensees from any and all claims that I, or any third party, may have now or in the future for invasion of privacy, right of publicity, copyright infringement, defamation or any other cause of action arising out of the use of my Personal Information.

4. WAIVER. I hereby waive any right to inspect or approve any Works that may be created using or containing my Personal Information and waive any claim with respect to the eventual use to which my Personal Information may be put, provided such use is consistent with the terms of this Release and Consent Agreement.

5. HOLD BACK FEES. I hereby release and agree Road 2 Recovery Foundation will retain a 10 (ten) % funding hold back of the total funds raised in my name via online donation, mailed donations, or at a fundraiser event. This holdback percentage is to cover all cost associated with the campaign of my account. I am aware of the payout policy of Road 2 Recovery and accept that no funds will be paid out to me directly, but will be paid out to all medical providers for approved expenses and needs.

6. GRANT PAYMENT PROTOCOL. I understand and accept the Road 2 Recovery funding and protocol will be followed and strictly adhered to.
- a. All bills and or invoices must be submitted for approval. These are not guaranteed to be approved and must qualify under medical necessity from the injury sustained by you, the guarantee, on this case. All bills/invoice must be itemized and show detailed expenses including date of service. Insurance co-pays and out of pocket expenses must include a copy of the Insurance EOB. Approval is based on funds available and medical necessity.
- b. Medical Necessity. No funds will be paid to me, my spouse, partner, fiancé/fiancée, parent or personal caregiver directly, but will be paid out to all medical providers, medical supply companies, home reconstruction companies, and adaptive equipment companies upon receiving approval of the bill/invoice. The bills/invoices submitted must be a direct expense from your injury in this case. Prior injury bills and/or outstanding invoices need to be submitted for approval on a case by case bases.
- c. Not Qualified for Approval. Spouse, partner, fiancé/fiancée, parent or personal caregiver’s personal bills do not qualify for approval. Personal bills are any and all bills that are not directly linked to your injury in this case. Previous unpaid or outstanding bills including credit card debt and any personal items that are not deemed a medical necessity will not be approved.
- d. Payment Time Frames. All invoice/bills that are submitted for approval consideration for direct payment from the Road 2 Recovery must be submitted to Mike Young or Anita Button within 10 (ten) days prior to payment due date. This is to elevate any unnecessary late fees and or interest and allows proper processing/negotiating time between the payee and Road 2 Recovery.
7. These payment protocols are in place and standardized to adhere to the Donation Guidelines and Mission Statement of Road 2 Recovery.

I am of full legal age, I have read this Release and Consent Agreement, and I am fully familiar with and understand the contents of this Release and Consent Agreement. By your signature below, a minor’s parent(s) or legal guardian(s) indicate, on behalf of their minor child, their full and unqualified consent to the terms of this Release and Consent Agreement.
Patient's Full Name*
First Last
Date of Birth*
Please enter a number from 4 to 99.
Last 4 of Social Security Number
Email*
Patient's Home Address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Do you have medical insurance you'd like us to add?
Insurance Company Name
Member ID
Primary Policy Holder Name
Group #
Please upload front and back images of your insurance card.
Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 50 MB.
Below information is not required if Athlete is a minor:
Do you have a preferred Practice or Provider?*
Name of Provider or Practice
City
State
Phone
Email
Press Release and Funding Page Information

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Road 2 Recovery Foundation Mental Health Grant Intake Form

Step 1 of 2 - Authorization to Release and Disclose Patient Information The Road 2 Recovery Foundation

1. Authorization to Release and Disclose Patient Information to The Road 2 Recovery Foundation

A. Patient Information

B. Authorization of Release of Protected Health Information

C. Revocation

D. Not Restriction on Treatment

E. Further Disclosures

F. Road 2 Recovery Hold Back

2. PATIENT'S PERSONAL INFORMATION

Press Release and Funding Page Information

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