Get Connected

Please complete the following form. Once you submit the form, a Community Health Associate from our team will contact you to complete an intake and discuss your form. We look forward to connecting with you!

Step 1 of 3

Name(Required)

First Last

Email(Required)

Phone(Required)

Are you currently experiencing homelessness?(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

Gender(Required)

Are you a veteran?(Required)

Yes

Date of Birth(Required)

Race(Required)

Ethnicity(Required)

Do you have health insurance?(Required)

What type of insurance do you have?(Required)

Where did you hear about us?(Required)

Thank you for reaching out to the UF Health St. Johns Care Care Connect - Resource Navigation program. At this time, we do not have community partners in your location to meet the needs that you have expressed. We are excited to expand our services and look forward to the time when we will be able to partner with services providers to meet these needs.

Until that time, your best option to learn about resources in your community may be by calling 2-1-1.

Purpose of this form: St. Johns Care Connect, Inc. (“the Agency”) is a participating provider of vital services (“Participant”) who is an active project of the Care Connect Information Network (CCIN) hosted by St. Johns Care Connect, Inc. CCIN participating agencies work together to provide services to persons and families in need. When you request or receive services, we may collect data about you and your household such as:

Your name, date of birth, Social Security Number, gender, ethnicity, race, veteran status, prior residence and program status.
Your service needs, income, benefits, education, employment, destination, disability, general health, as well as pregnancy, HIV/AIDS, behavioral health, legal, and domestic violence status, destination.
How will my data be used? The ways in which the Agency may use or disclose your information are discussed in our Notice of Privacy Practices, which is posted here: Privacy Policy.
How will my data be protected? We enter your data in a computer program that is protected by passwords and encryption technology. Each Participant and CCIN user must sign an agreement to maintain the security and confidentiality of the information. Any person or Participant that violates the agreement may lose their access rights and be subject to further penalties.
How do I benefit by providing the requested information and sharing it with other agencies? By sharing your information with other agencies, you may be able to avoid being screened again, get services faster, and minimize how many times you have to tell your “story.” You also help agencies document the need for services and demonstrate that funding is needed.

Client Informed Consent/Authorization for Release of Information - By signing this form, I agree that the Agency may disclose and other participating agencies in the SERVICEPOINT may use the following information for lawful purposes of the agencies that participate in the SERVICEPOINT and their employees and agents:(Required)

List the individuals affected by this Release of Information (ROI). If this is a household situation, please include household members affected by this ROI.(Required)

Signature of the Individual or Guardian (typed name)(Required)

I agree that this agreement may be electronically signed. I agree that the electronic signature appearing on this agreement is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility. I understand that •I am not required to sign this consent and that if I refuse to sign this consent my treatment, payment, or eligibility for benefits will not be affected. I may also request a copy of this consent after I sign it.

By submitting this form, I agree to share all of my information with Care Connect and other participating agencies in the Care Connect Information Network. Care Connect will only disclose my information to agencies on a need to know basis. Care Connect will advocate on my behalf based on the services being requested and information I provide. If I request services from another partnering agency, the information I have shared with Care Connect will be viewable to the partnering agency avoiding duplicative screening.

Get Connected

Please complete the following form. Once you submit the form, a Community Health Associate from our team will contact you to complete an intake and discuss your form. We look forward to connecting with you!

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