Healthcare Community Living Form

HEALTHCARE COMMUNITY LIVING FORM

Client Name:   Date of Birth:   Client ID:

Resident Information

Male    Female    Non-binary    Prefer not to say

Placement and Program Details

Medical Provider & Insurance

Medical History

Functional Abilities & Support Needs

Mobility: Independent    Supervision required    Assistance required    Dependent

Bathing    Dressing    Feeding    Toileting    Medication management

Consents and Authorizations

Medication Administration: I authorize trained program staff to administer medications to the client in accordance with prescriber directions and facility medication policies. Staff will document administration and notify prescriber and guardians according to policy. I understand I may refuse this authorization and will be responsible for arranging alternate medication administration.

I consent to medication administration by program staff.    I refuse medication administration by program staff.

Emergency Medical Treatment Authorization: In the event of an emergency where the client lacks capacity to consent, I authorize program staff to obtain emergency medical care, including transport, hospital admission, and lifesaving treatment. Staff will make reasonable efforts to notify the emergency contact or legal representative as soon as practicable. If I wish to limit emergency interventions, I will specify below.

Transportation & Community Access: I authorize staff to transport the client for medical appointments, community activities, and necessary errands consistent with the client's service plan. Transportation will be provided only by authorized staff or contracted providers.

I consent to staff-provided transportation.    I have concerns regarding transportation (describe below).

Release of Information & Privacy Acknowledgment

Authorization to Disclose Health Information: I authorize the program to share and receive protected health information as necessary for treatment, care coordination, billing, and quality assurance with the client's health care providers, payers, contracted service providers, and designated representatives. This authorization includes verbal and written information, medication records, and relevant clinical assessments.

I understand that I may revoke this authorization at any time by providing a written revocation, except to the extent the program has already acted in reliance on the authorization. Revocation does not affect disclosures made prior to receipt of the revocation.

HIPAA / Privacy Acknowledgment: I acknowledge receipt of the program's privacy practices and understand how my health information will be used and shared for care coordination.

Acknowledgment and Consent

By signing below, I certify that the information provided in this Healthcare Community Living Form is true and complete to the best of my knowledge. I understand the nature of the services, consents, and authorizations herein, and I consent to the provision of care and supports described in the client's individualized service plan consistent with applicable laws and program policies. I understand I may withdraw any consent in writing and that withdrawal will not affect actions taken prior to receipt of the withdrawal.

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