Healthcare Residential Care Form

Healthcare Residential Care Form

Facility / Admission Details

Facility Name:

Resident Information

Date of Birth:    Gender: Male Female Other:

Primary phone:    Secondary phone:

Emergency & Responsible Party

Relationship:    Phone:

Healthcare Providers & Insurance

Policy number:    Group number:

Medical History & Functional Status

Please indicate current and past medical conditions (check all that apply):

Diabetes Hypertension Heart disease COPD / Asthma Dementia / Cognitive impairment Depression / Anxiety

Mobility / assistance needs: Independent Cane/walker Wheelchair Transfer assistance

Advance Directives & Legal Authorizations

Does the resident have an advance directive or durable power of attorney for healthcare? Yes No

Do-Not-Resuscitate (DNR) or similar orders included? Yes No

Consent for Care, Treatment and Release of Information

I, the undersigned resident or authorized representative, authorize the facility and its agents and contractors to provide residential care, skilled or personal care services, routine nursing services, assistance with activities of daily living, medication administration as ordered by the resident's physician, and emergency treatment as necessary. I understand that the facility will make reasonable efforts to contact my physician and the person(s) listed as emergency contacts when urgent care is required.

I authorize the release and exchange of medical and personal information necessary for my care and treatment, including release to physicians, pharmacies, laboratories, emergency services, payors, and other providers for continuity of care. This authorization includes access to prior medical records obtained by the facility for assessment and admission purposes.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. I understand that refusing to sign this form will not affect my ability to obtain treatment; however, I acknowledge that failure to authorize release of necessary information may impede admission or provision of services.

Privacy & HIPAA Acknowledgment

By signing below I acknowledge receipt of the facility's privacy practices and notice of privacy rights. I authorize the facility to use and disclose protected health information as required for treatment, payment and healthcare operations and as otherwise permitted or required by law. I understand my rights to inspect and request amendment of my records as provided by law.

I give permission for the facility to share pertinent health information with the following persons: Name(s) and relationship(s)

Photographs, Transportation & Special Consents

I consent to the use of photographs or video of the resident for care documentation and facility records: Yes No

I authorize the facility to arrange non-emergency and emergency transportation as required for care and appointments: Yes No

Financial Responsibility

I understand that by signing this form I or the responsible party agree to be financially responsible for charges not paid by insurance, including private pay amounts, co-payments, deductibles, and fees for services not covered by insurance. I authorize assignment of benefits to the facility where applicable.

Certification & Acknowledgment

I certify that the information provided on this form is true, correct and complete to the best of my knowledge. I understand that intentional misrepresentation of medical, financial or legal information may result in termination of residency and collection actions. I acknowledge my right to withdraw consent in writing as specified above.

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