Healthcare Senior Care Center Form

Healthcare Senior Care Center Form

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Emergency Contact

Relationship:    Phone:

Primary Medical & Pharmacy Information

Physician Phone:    Preferred Pharmacy:

Pharmacy Phone:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Status

Please indicate chronic conditions (check all that apply):

Hypertension Diabetes COPD/Asthma Heart disease

Renal disease Dementia / Cognitive impairment Cancer Other (describe below)

Mobility status:

Uses assistive device: Walker Wheelchair Cane

Consent for Care and Treatment

I, the undersigned, authorize Healthcare Senior Care Center and its licensed staff and agents to provide routine and emergency healthcare services appropriate to the care setting, including but not limited to: assessment, medications as prescribed, wound care, basic diagnostic procedures, and coordination with outside providers. I understand that staff will follow the orders of my treating physician and that every reasonable effort will be made to obtain informed consent for procedures whenever practicable.

I acknowledge that no guarantee has been made as to the results of any treatment. I authorize staff to administer medications and treatments as documented in my plan of care and to act in my best interest in an emergency, including arranging transport to an acute care facility if necessary.

I understand I may withdraw this consent at any time by notifying the facility in writing. Withdrawal will not affect any care or actions taken prior to receipt of revocation.

By checking this box I give my informed consent to the above care and treatment provisions.

Privacy, Authorization & Release of Information (HIPAA)

I acknowledge receipt of the facility's Notice of Privacy Practices and understand that personal health information may be used and disclosed for treatment, payment, and healthcare operations as permitted by law. I authorize the facility to disclose my protected health information to the persons listed below for the purposes of care coordination, discharge planning, and family communication.

Authorization Expiration Date:

I understand that I may revoke this authorization at any time by submitting a written revocation to the facility, except to the extent that action has already been taken in reliance on this authorization.

Release of Medical Records

I authorize Healthcare Senior Care Center to release medical records and billing information to the persons or organizations identified above and to my insurance carriers as necessary for payment and continuity of care. This authorization includes release of sensitive information when required for treatment or payment, except where I have indicated restrictions below.

Advance Directives & Authorized Representatives

Do you have an advance directive or durable power of attorney for healthcare?   Yes No

Do-Not-Resuscitate (DNR) or similar orders present:   Yes No

Facility Acknowledgments & Notices

The facility maintains policies to protect patient confidentiality and will make all reasonable efforts to communicate with designated contacts. This form does not create a guarantee of specific staffing levels or outcomes. The facility will comply with applicable law in reporting communicable disease and in responding to public health requirements.

Acknowledgment & Certification

By signing below I certify that the information I have provided is correct to the best of my knowledge, that I have the authority to sign on behalf of the patient if signing as an agent or representative, and that I understand the content of this document including the consents and authorizations contained herein.

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