Self-referral patient form

KC Fresh Rx is a healthy food incentive program for people who:

• Receive their insurance through Medicaid (KanCare or MO HealthNet) 
• Have been diagnosed with at least one of the following: 
  • Pre-hypertension
  • Hypertension
  • Pre-diabetes
  • Diabetes (well controlled and not on insulin)
• Have struggled with having enough food in the past year

This six-month program includes a reloadable gift card to purchase fresh fruits and vegetables and nutrition education. A follow-up evaluation meeting occurs after the six months. Patients are required to attend the first and last sessions in person.

Instructions: If you feel you are eligible for this program, please fill out all sections of this form. Once completed, this form will be sent to the healthcare provider at your clinic.

If you are eligible, the KC Fresh Rx coordinator will contact you from 816-474-4240 regarding enrollment. By filling out this form, you consent to be contacted by the KC Fresh Rx coordinator.  
Contact 816-701-8247 if you have questions or need help filling out this form. 

I authorize the health care provider(s) identified below to use and/or disclose the health information described in this authorization to the representatives of the recipient(s) identified below, for the purposes described below.

Recipient name: Mid-America Regional Council (MARC), KC Fresh Rx Program 
Recipient address: 600 Broadway, Ste. 200, Kansas City, MO 64105 
Recipient phone number: 816-474-4240 

I authorize the Clinic to release to the Recipient all personal health information (PHI) from my medical record(s) created in the past, present or future (up to the expiration or revocation date of this authorization), that is reasonably relevant to:

• Confirming my eligibility for the KC Fresh Rx Program and/or related nutrition support services; and 
• Administering my participation in the program (including enrollment, ongoing eligibility, care coordination related to the program, and program follow-up). 

This information may include as applicable, clinical information, health status information, diagnoses/condition, care summaries, test or screening results, measurements/vitals, treatment information, medication information, and other information relevant to the program’s eligibility criteria and administration, as maintained by the Clinic.

The purpose of this disclosure is to allow the Recipient to determine whether I qualify for the KC Fresh Rx Program and, if approved, to administer and coordinate services provided through the program.

By signing this authorization, I understand that:

• I have a right to receive a signed copy of this authorization. A photocopy of this authorization is as valid as the original. 
• I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Clinic and Mid-America Regional Council. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire one year from the date signed.
• I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment.
• I understand that I may inspect or obtain a copy of the information to be used or disclosed.
• I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure, and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Recipient of Clinic.

I have read and understand this authorization and authorize the use and/or disclosure of my health information as described above.