Parkinson’s Wellness Fund Application

Client Consent: Client readily understands that it is allowing the Parkinson’s Wellness Fund and the Fund’s supporting entities, the MEYROW Foundation, (collectively hereinafter referred to as “PWF”) to utilize this information for confidential purposes only. Client acknowledges that it is freely disseminating this information to PWF and that Client has the full authority to disseminate such information to PWF. PWF assumes no risk or liability for any information that Client has disclosed in this document. Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between PWF and other third parties/entities. If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.

Release of Liability: Client shall release PWF from any and all liability, known or unknown, at the time in which this information is disclosed by Client in this document or any future dissemination communicated verbally or in writing to PWF. Client further releases PWF from any liability pertaining to PWF’s use of Client’s information. PWF shall protect and keep all of Client’s information confidential and shall only transmit such information to other entities and third parties when necessary to carry out of the functions and objectives of PWF in order to serve the potential needs of Client.

Privacy Policy: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered client confidential, is restricted by law, or has been specifically restricted by a client.