Healthcare Caregiver Paperwork

Healthcare Caregiver Paperwork

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Caregiver Information (for provider records)

Scope of Care and Duties

Care to begin on:   Location of care:

The caregiver's duties include, but are not limited to: personal care, assistance with activities of daily living, mobility assistance, meal preparation, medication reminders, and monitoring of health status. Specific duties and limitations are set forth below and must be performed in accordance with applicable professional standards.

Medical History & Current Health

Medication Administration & Related Authorizations

I authorize the caregiver to administer medications as directed in writing by my prescribing clinician and in accordance with medication administration instructions provided below.

I permit the caregiver to store, handle, and administer the above medications in accordance with written physician orders and the medication administration protocol described herein.

Consent to Share Health Information & HIPAA Acknowledgment

I authorize the caregiver to share necessary health information with the following persons and entities for the purpose of providing care, coordinating treatment, and responding to emergencies. I acknowledge receipt of the provider's privacy practices and understand my rights regarding protected health information.

Share information with treating physicians as needed.

Share prescription and medication information with pharmacy providers.

I acknowledge the privacy practices and consent to disclosure consistent with care provision and legal requirements.

Emergency Treatment Authorization

If an emergency occurs and I am unable to communicate, I authorize the caregiver to seek emergency treatment and to transport me to the nearest appropriate medical facility. Where feasible, the caregiver will attempt to contact my emergency contact and primary physician prior to or concurrent with emergency care.

Legal Terms, Liability, and Indemnification

The caregiver shall perform duties in a manner consistent with accepted standards of care and training. The caregiver is not responsible for outcomes resulting from the patient's refusal of recommended clinical care or nondisclosure of pertinent medical information. The patient releases and holds harmless the caregiver and employing agency from liability for ordinary negligence in the administration of approved care, except in cases of willful misconduct or gross negligence. The patient understands that certain activities (e.g., advanced clinical procedures) may be outside the caregiver's authorized scope of practice and will not be performed unless separately authorized in writing by the patient's clinician.

Acknowledgments, Attestations, and Expiration

By signing below, I attest that the medical information I have provided is accurate to the best of my knowledge, I consent to the caregiver performing the duties described herein, and I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. This authorization expires on the date specified below or upon written revocation, whichever occurs first.

Expiration Date:

Insurance Information (if applicable)

Acknowledgment Checkboxes

I acknowledge that I have reviewed and understand the scope of services and caregiver responsibilities described in this document.

I attest that the caregiver's immunization and screening information on file is accurate and current, or that I have been informed of any limitations in caregiver immunization status.

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