Healthcare Care of AL Form

Healthcare Care of AL Form

Facility / Resident Identification

Facility Name:    Room/Unit #:

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group #:

Medical History & Current Conditions

Mobility assistance required: Ambulation assistance Uses wheelchair Fall risk

Other needs (oxygen, feeding tube, incontinent care):

Scope of Care & Authorization

I hereby authorize the facility named above and its licensed and trained staff to provide routine personal care, assistance with activities of daily living, medication administration, monitoring of health status, and coordination of medical services as necessary to meet the resident's needs. The scope of authorized services includes the following specific items (describe limitations or special instructions):

Medication Administration

I authorize staff to administer prescription and over-the-counter medications in accordance with the prescriber’s orders and facility policy. I understand that licensed nursing staff will record administration and monitor for adverse effects. I acknowledge the following choice:

I consent to medication administration by facility staff.
I decline medication administration by facility staff; I will arrange for medication management externally.

HIPAA / Privacy & Information Release

By signing this form I acknowledge the facility's Privacy Practices and authorize the release and exchange of my protected health information among facility staff, treating physicians, pharmacies, emergency responders, and other providers as necessary for treatment, payment, and health care operations. I specifically authorize release of medical information to the following persons for care coordination:

I acknowledge receipt of the facility's privacy notice and authorize disclosures as described above.

Emergency Medical Treatment & Transport

In the event of an emergent medical condition, I authorize the facility to arrange emergency assessment, transport to an appropriate medical facility, and treatment as directed by attending healthcare professionals. I understand that every effort will be made to notify the emergency contact prior to or promptly after transport.

I consent to emergency medical treatment and transport.    I decline emergency transport except as required to prevent immediate harm.

Advance Directives & Legal Representative

I have been asked whether I have an advance directive (such as a living will, durable power of attorney for health care, or do-not-resuscitate order). Please indicate status and provide a copy if available.

Advance directive is on file with the facility.    No advance directive on file.

Relationship to patient:    Contact Phone:

Authorization Period, Withdrawal, Liability

This authorization will remain in effect until revoked in writing by the patient or the patient's legal representative, or until the patient is discharged from the facility. To revoke this authorization, written notice must be delivered to facility administration and will be effective upon receipt.

Authorization Expires on:

The facility and its staff will exercise reasonable care in providing services. This authorization does not waive any rights the patient may have under applicable law. The patient acknowledges that the facility is not responsible for adverse outcomes resulting from conditions beyond the facility's control or from the patient's failure to disclose accurate medical information.

Certifications & Acknowledgments

I certify that the information on this form is true and complete to the best of my knowledge. I understand the nature and purpose of the care and authorizations described above, including potential benefits and risks associated with medication administration and emergency treatment. I understand my right to refuse any specific treatment and the procedure for revoking this authorization.

Patient or Legal Representative Initials:

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