HEAT

Your household is located within the HEAT service area. Please continue to the next section to determine whether you may qualify for heating oil assistance.

Your ZIP code is not currently included in the HEAT service area. Thank you for your interest in Orion’s HEAT Program. At this time, your household is not eligible to proceed with the HEAT application You may still be eligible for other assistance or resources through Orion Communities. Please contact our Case Management Team at 610-415-1140 to discuss your situation and available options.

Please contact our case management team at 610-415-1140 to further discuss your eligibility and other assistance and resources that may be available to you.

Please contact our case management team at 610-415-1140 to further discuss your eligibility and other assistance and resources that may be available to you.

Authorization to Release Information (Gateway/HEAT)

IN ORDER TO COORDINATE SERVICES BETWEEN THE AGENCIES INVOLVED IN THE DISTRIBUTION OF HEAT FUEL ASSISTANCE, CERTAIN INFORMATION ABOUT YOU WILL BE SHARED WITH THE PARTICIPATING AGENCIES. THIS DOCUMENT OUTLINES WHAT INFORMATION WILL BE SHARED, AND OBTAINS YOUR PERMISSION TO DO SO.

I hereby authorize Orion Communities to release to Gateway Housing Group, their funding partners, and the participating agencies, institutions, or parties listed below, the following information:

Your Name, Address, Household Composition, LIHEAP Status, Household Size, Number of Children in the Household, Age Range of Head of Household, Tenant/Homeowner, their Employment Status, Type of Fuel Assistance and Amount Received, and Circumstances of Need

Agencies/Caseworkers Receiving Information: Gateway Housing Group, Orion Communities, Spring Ford Project Outreach, Pottstown Cluster of Religious Communities, Manna on Main Street, ACT in Faith.

By signing this you agree that the information indicated above may be released to the agencies, organizations, party or parties indicated. Your information may also be kept in an online database for their shared use until the end of this years program in April.

This consent will not expire. I understand that I may revoke this consent at any time by notifying this Agency in writing, which will be delivered to the Agency by Certified Mail, except to the extent that action has been taken in reliance on my consent.

I hereby authorize Orion Communities to obtain and release the following confidential information: demographics, insurance, income, and all information pertinent to providing case management services.

I understand that all information obtained by Orion Communities will remain confidential and only be available to Orion staff as necessary for me to receive services.

I understand I have the right to request to see my file, files will be provided within 24 hours of request. I understand that I can revoke this consent in writing to both the person giving and the person receiving the information. Any information already released may be used as stated on the consent. I understand the requested or provided information is needed to determine eligibility for housing and/ or social services. I understand that this information may be released without my permission as explained below:

• If I am a danger to myself the case manager/staff may take steps to seek involuntary hospitalization.
• If I threaten to kill or seriously harm someone and my case manager/staff believes I may carry out the threat, they will reach out to appropriate authorities
• If necessary for me to be hospitalized for psychiatric care.
• If the case manager/staff member believes that a child, disabled individual, or a older adult in my care is experiencing abuse or neglect of any kind.

This consent is valid only until one year from date signed and does not automatically renew.
By my signature, below, I affirm that I have read this release, or it has been read to me, and I understand its content.

NOTE: Consent must be signed by the client, guardian, or next of kin. If an individual is physically or mentally incompetent, the Power of Attorney may sign for the client.