Rapid HIV Home Testing Kit

Your safety is our priority. During COVID-19 restrictions, Cempa Community Care is offering FREE HIV Home Testing Kits. Please fill out the form below to receive an HIV Home Testing Kit. After submitting the form, you will receive your kit between 24-48 hours. Please ensure to contact us with your results within 48 hours. 

Rapid HIV Home Testing Kit Form

Statement of Confidentiality and Privacy Notice-I understand that any and all my information pertaining to services through Cempa Community Care (CCC) is strictly confidential and is protected by HIPAA.  I am aware that my information is not to be disclosed to or discussed with persons who are not employed by Cempa Community Care, and only with those of Cempa Community Care who are relevant to the services provided to me.

Title Vl Grievance Notification- Cempa Community Care conducts its programs and projects without regard to race, color, or national origin in accordance with 1964 Title VI of the Civil Rights Act. Any person who believes she or he has suffered due to unfair treatment by any unlawful discriminatory practice under Title VI may file a complaint with the TN State local Title VI representative below or initiate a formal grievance as described in the policy to seek an equitable solution. You shall not be subjected to coercion, discrimination, reprisal, or unreasonable interruption of services for voicing complaints or recommending changes.

Declaración de confidencialidad y aviso de privacidad- Entiendo que toda mi información relacionada con los servicios a través de Cempa Community Care (CCC) es estrictamente confidencial y está protegida por HIPAA. Soy consciente de que mi información no debe divulgarse ni discutirse con personas que no estén empleadas por Cempa Community Care, y solo con aquellas de Cempa Community Care que sean relevantes para los servicios que se me brindan.

Título Vl Notificación de reclamo-Cempa Community Care lleva a cabo sus programas y proyectos sin distinción de raza, color u origen nacional de conformidad con el Título VI de 1964 de la Ley de Derechos Civiles. Cualquier persona que crea que él o ella ha sufrido debido a un trato injusto por cualquier práctica discriminatoria ilegal bajo el Título VI puede presentar una queja ante el representante local del Título VI del estado de TN a continuación o iniciar una queja formal como se describe en la política para buscar una solución equitativa. No estará sujeto a coerción, discriminación, represalia o interrupción irrazonable de los servicios por expresar quejas o recomendar cambios.

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