Apply for Support – Equip Resource Solutions

Please review and agree to the following before submitting:

HIPAA Authorization & Notice of Privacy Practices: I acknowledge that I have been provided the opportunity to review the HIPAA Notice of Privacy Practices for Equip Resource Solutions. I authorize ERS to collect, use, and retain the health-related and personal information provided in this form for the purpose of evaluating my application and coordinating support services. I understand I may revoke this authorization at any time by contacting [email protected]. *

Data Sharing Authorization: I authorize ERS to share my information with affiliated organizations within the Equip Human Solutions ecosystem — including Western Medical Training Center (WMTC) — solely for the purpose of coordinating the services I have requested. I understand this information will not be sold or shared for marketing purposes. *

Privacy Policy: I have read and agree to the Privacy Policy. I understand my rights under CCPA and HIPAA, including the right to access, amend, or request deletion of my information. *

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