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Maui County Consumer Registration Form

Please read and agree to the following consent form
Consent Form
  1. I, the person whose Name, and Date of Birth appear within this document, understand that this information is being collected for MAUI COUNTY. I hereby grant permission, consent, and authorization to Maui County to release and disclose all information contained in the Senior Citizen Registration Form, including protected health information, to Maui County�s consultants, contractors, and any other persons or entities involved in the administration, and/or enforcement of its programs and services.
  2. The purpose of this Consent is to comply with any requirements, relating to the use and disclosure of protected health information. The information obtained will be used and disclosed for the purposes of providing information and assistance, reporting, processing, administration, and/or determination of my application for programs and services to the elderly. These programs and services include, but are not limited to, information and assistance, case management, personal care, day care, homemaker chore, transportation, attendant care, home modifications, home-delivered meals, congregate meals, legal, outreach, and community health development.
  3. This consent is revocable in writing at anytime. This Consent shall remain valid until written revocation from me is received by Maui County. It is understood that this Consent constitutes an express waiver of any rule against disclosures otherwise provided by any confidentiality provision of Federal, State, or other applicable law.
  4. I hereby release the County of Maui, its officers and employees, and the County of Maui�s funding sources, agents, attorneys, insurers, consultants, experts, and contractors, from all liability and all claims pertaining to use or disclosure of information, or of any professional opinions, findings, or recommendations as contained in the information, records and reports to which this Consent applies.
  5. I have read and understood this Consent Form.

For Help Call:
Statewide 643-ADRC(2372)
Maui 808-270-7774
Molokai 808-553-5241
Lanai 808-565-6818

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