Healthcare Living Relative Statement

Healthcare Living Relative Statement

This Healthcare Living Relative Statement is a sworn declaration by a relative or household member who resides with the patient and who provides or assists with the patient’s daily living needs. The declarant affirms the factual information provided below for purposes of health care coordination, benefits eligibility, care planning, emergency contact designation, and related administrative determinations. The declarant understands that knowingly providing false information may subject the declarant to civil or criminal penalties under applicable law.

Patient Information

Patient Name:

Declarant (Living Relative) Information

Living Arrangement Details

Shared Residence Address:

I confirm that the patient resides at the shared address above: Yes No

Caregiving and Financial Support

The declarant performs or assists with the following activities (check all that apply):

Medication management or administration
Personal hygiene and bathing
Meal preparation or feeding
Mobility assistance and transfers
Transportation to appointments
Other caregiving tasks (describe below)

Yes No

Documentation and Verification

I understand that the organization may verify residency and relationship by requesting supporting documentation. The following documents are attached or will be provided upon request (check all that apply):

Utility bill in shared name or address
Lease or mortgage statement
Photocopy of government-issued ID
Other supporting documents (describe below)

HIPAA / Privacy Acknowledgment

By checking the box below, the declarant acknowledges that the declarant has read and understands that the patient’s protected health information may be accessed, used, or disclosed to the declarant for purposes of care coordination, treatment, billing, and administrative functions as permitted by applicable privacy laws and the patient’s prior authorizations.

I acknowledge and consent to the privacy and information-sharing statements above.

Legal Certification and Authorization

I certify under penalty of law that the information provided in this statement is true, complete, and correct to the best of my knowledge. I authorize the organization and its representatives to verify any information contained in this statement, including contacting third parties and reviewing documents provided as verification. I understand that the organization may rely on this statement in determining eligibility for services, benefits, and care arrangements, and that knowingly providing false information may result in denial of services and potential civil or criminal penalties.

Additional Information

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