Consent Form to Release Health Information for the purpose of improving housing stability

I give permission for Nexa Home Connect staff to talk with property managers on my behalf when the topic of conversation pertains to housing stability for me.

I give permission for Nexa Home Connect to talk with social service professionals on my behalf when the topic of conversation pertains to housing opportunities for me.

I give permission for Nexa Home Connect to talk with mental and/or physical health professionals on my behalf when the topic of conversation pertains to housing opportunities for me.

By signing this form, I acknowledge that I am giving permission for Nexa Home Connect to work with me on housing stabilization. I am giving permission for the staff of Nexa Home Connect to seek information from medical and social service professionals if the purpose is to improve my housing stability.

I am requesting that health information be released from my health care provider to Nexa Home Connect staff when this information will be used to improve my housing stability

The genetic information nondiscrimination act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting genetic information of any individual or family member of the individual, except as specifically allowed by this law. Nexa Home Connect has no interest and will not be involved with genetic information in any way.

I do not give permission for Nexa Home Connect to work with me on housing stabilization or seek information to improve my housing stability

I understand that my consent lasts for one year, and that I will need to renew this consent if service continues past one year.

Nexa Home Connect

Address: PO Box 3611

Minneapolis, MN 55403

Fax: 612-234-4524

We provide office hours at various sites in the Twin Cities

Daniel Johnson can be reached at 612-720-2634 or dan@nexahomeconnect.com.

Dr. Kirstin Bratt-Johnson can be reached at 612-888-6392 or kirstin@nexahomeconnect.com.