Monroe County, FL - Special Needs Registry Form

Special Needs Registry Form

Fillable


	Individuals are eligible to be registered with the Special Needs Registry if they are frail, elderly, medically needy, and/or disabled and are not served in or by a residential facility program. Eligible clients are required to complete and sign the following application as well as the HIPAA Disclosure of Information and HIPAA Privacy Act forms before they will be placed on the registry. To register click one of the following links: Special Needs Registration Form (fillable) Fill the form out online, then print the form out on your computer and mail it to the following address: Special Needs Registration Form (printable) Print the form out on your computer and mail it to the following address: Special Needs Registry 1100 Simonton St Room 1-180 Key West, FL 33040 If you have any queastions contact the Special Needs Coordinator Anna Haskins or call 305-292-4591.