Serving Our Seniors LLC Agreement and Release of Health Information
I am currently working with Serving Our Seniors LLC for the sole purpose of identifying senior living options. My Advisor will provide guidance to me and my family while choosing an appropriate living arrangement. The service is provided to me free of charge. I understand my Advisor will suggest viable options to me but the final decision is mine.
I declare that I have the authority to engage Serving Our Seniors LLC in this agreement by virtue of my title (choose one):
Self
Spouse
Power Of Attorney
Legal Guardian
Family Member
Case Manager
Other Legal Agent
In addition, by returning this form and with my signature below, I authorize any hospital, physician or any other medical person who has attended to or examined me, the patient named below, to furnish any and all information to Serving Our Seniors LLC with respect to any illness, injury, medical history, consultation, prescription or treatment and copies of all hospital and medical records. Information may be redisclosed and no longer be protected. The individual has the right to revoke the authorization at any time by submitting a written request to Serving Our Seniors LLC. This consent will expire sixty days past the date entered below.
Date
-
Month
-
Day
Year
Today's Date
Patient Name
First Name
Last Name
Patient's Date of Birth
-
Month
-
Day
Year
Date of Birth
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.
Doctor's Name
First Name
Last Name
Doctor's Phone Number
Please enter a valid phone number.
Signature
Specific Information Typically Requested:
Most recent history & physical, lab work, chest x-ray, medication list, demographic information, date of last flu vaccine, & date of last Pneumococcal vaccine.
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