Clone of Intake Form

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Submitted by egskynet on Tue, 03/27/2018 - 01:44
*CONSUMER ELIGIBILITY

To be eligible for Northern Nevada Center for Independent Living services, a person must experience a significant disability which limits their ability to function independently. In order to document that you are eligible for our services, please answer the following:

CONSUMER INFORMATION
EMERGENCY CONTACT INFORMATION
Intake Questions
SERVICES REQUESTED
GOALS SET

For Staff Use Only

INDEPENDENT LIVING PLAN / WAIVER

 

Provide the consumer a copy of the signed/waived ILP.

RELEASE OF INFORMATION

These activities may include audits, investigations, and inspections, requesting and follow-up of application. These activities are necessary for NNCIL to perform our obligation to our consumer as well as to be in compliance with civil rights laws. Your personal and disability information entrusted to NNCIL will only be disclosed upon signing the release of information. If you provide us with authorization to use or disclose your personal and disability information to federal centers, state and local agencies, you may also revoke this authorization in writing at any time. When we receive your written revocation, we will no longer use or disclose your health information for the purpose intended.

By signing below, I am authorizing the release or exchange of these records to the parties marked above.

Provide the consumer a copy of the signed form.

CONSUMER GRIEVANCE PROCEDURE

A grievance is an act, omission or occurrence that can be established on factual information or evidence including, but not limited to : dates ,times, places, and names of the other persons involved in the act, omissions or an occurrence in which the consumer feels constitutes injustice.

The following steps will serve as a guide for the resolution of grievances:

  • An aggrieved consumer shall make his grievance known to his or her advocate.
  • In the event that the grievance has not been resolved by Step 1, the consumer or his or her parent or guardian has the right to put his or her grievance in writing and present it to the Executive Director.
  • The Executive Director will then present the written grievance to the advocate and arrange a personal conference with the parties involved.
  • The Executive Director shall have final jurisdiction in the resolution of the grievance within 10 business days from the date the letter of grievance was submitted by the consumer.

If you feel the need for more information about your rights as a applicant or consumer of the Northern Nevada Center for Independent Living, you can contact the CLIENT ASSISTANCE PROGRAM (CAP) through the Nevada Disability Advocacy and Law Center (NDALC).

The Client Assistance Program (CAP) can be contacted at any of the following locations :

Southern Nevada Northern Nevada Elko Office
2820 West Charleston Blvd. ,Suite 11
Las Vegas, NV 89102
Phone: 702-257-8150
Toll-Free: 1-888-349-3843
Nevada Relay: 711
Fax: 702-257-8170
lasvegas@ndalc.org
1875 Plumas Street
Suite 1
Reno, NV 89509
Phone: 775-333-7878
Toll-Free: 1-800-992-5715
Nevada Relay: 711
Fax: 775-786-2520
reno@ndalc.org
905 Railroad Street, Suite 104B
Elko, NV 89801
Phone: 775-777-1590
Toll-Free: 1-800-992-5715
Nevada Relay: 711
Fax: 775-753-1690
elko@ndalc.org

CAP provides Ombudsman services and can assist you if you have been denied services from any agency that provides services under the Rehabilitation Act. If a misunderstanding occurs between you and your advocate, CAP can provide mediation to resolve problems and assure fairness on all sides.

By signing below, I have received a copy of the NNCIL Consumer Grievance Procedure.

Provide the consumer a copy of the signed form.