Healthcare Specialized Living Form

HEALTHCARE SPECIALIZED LIVING FORM

Resident / Patient Information

Date of Birth:    Gender: Male Female Non-binary Prefer not to say

Insurance & Billing

Medical & Functional History

Mobility: Independent Requires assistance Wheelchair Other:

Cognitive / Behavioral Status: Intact Impairment noted Memory loss   If impaired, describe interventions or triggers:

Care Preferences & Services Requested

Level of assistance requested (select all that apply): Personal care (bathing, grooming) Medication administration Meal assistance / special diet Therapy / rehabilitation

Authorizations, Consents & Acknowledgments

I certify under penalty of law that the information provided on this form is accurate and complete to the best of my knowledge. I authorize the facility and its authorized agents to provide and coordinate care, including but not limited to routine personal care, medication administration, emergency medical treatment, transportation to medical appointments, and coordination with outside health care providers as necessary for my care. I understand that the facility will act in accordance with applicable professional standards and regulatory requirements.

Consent to Medication Administration: I authorize staff to administer prescribed medications and over-the-counter medications as ordered by my physician, in accordance with facility policy.

Emergency Treatment Authorization: I authorize emergency medical treatment if I am unable to consent at the time of emergency. Where delay would be detrimental to my health, staff may consent to medically necessary treatment on my behalf.

Release of Medical Information: I hereby authorize the release and exchange of medical information between the facility and my listed health care providers, insurance carriers, and other entities as necessary for the provision of care and billing. This authorization includes release of past and future medical records reasonably related to ongoing care for a period ending on the date specified below.

HIPAA Privacy Acknowledgment: By signing below I acknowledge that I have been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights regarding that information. I understand that I may request restrictions on certain uses and disclosures and that such requests will be considered by the facility in accordance with applicable law.

Withdrawal of Authorization: I understand that I may revoke this authorization at any time by delivering a written revocation to the facility's administration, except to the extent that the facility has already taken action in reliance on this authorization. Revocation will not affect disclosures made in reliance on the authorization prior to receipt of revocation.

Additional Administrative Provisions

Facility Policies: I agree to comply with facility rules and policies regarding safety, visitation, medications, smoking, and Code of Conduct. The facility maintains the right to revise policies and will communicate material changes.

Liability Limitation: While the facility will use reasonable care in providing services and maintaining a safe environment, I recognize that certain risks are inherent to residential living and health care. Except for negligence or willful misconduct, I release the facility from liability for incidents arising from such inherent risks, subject to applicable law.

Resident Statement and Certification

I certify that I have read and understand the foregoing statements, that the information I have provided is true and complete, and that I have the authority to execute this form. I understand that falsification or omission of material information may result in termination of services. By signing below I give informed consent to the terms stated in this Healthcare Specialized Living Form.

Sign Now