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Medical Release Form

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Medical Release Form

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Authorization to Obtain and Release

Medical Records or Health Care Information

 

I hereby request and authorize A1 Senior Care Advisors LLC  to receive copies of my Medical Records and or Health Information including medical history, diagnosis, medication lists and chart notes. I give permission for A1 Senior Care Advisors LLC to speak with my health care representatives on my behalf to gather information that relates and pertains to my long-term care. I also ask that an A1 Senior Care Advisors representative to be included in care conferences and discharge planning.

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I understand I can refuse to sign this authorization. I understand that I will receive a copy of this form after I sign it. I understand that I can revoke my authorization at any time in writing. Revocation will be effective immediately when received in writing by the Source Releasing the Information and A1 Senior Care Advisors LLC.  I understand that the revocation will not apply to information that has already been released in response to this authorization. Without a revocation request this signed authorization will stay in effect until the needs for disclosure are satisfied. I have read this form, or it has been read and explained to me, and I understand its content.
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medical records release form free, free medical authorization form1.425.324.5592

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medical release of information form free, medical release forms for adultsa1careadvisors@gmail.com

DROP US AN EMAIL AT ANYTIME, We WILL REPLY TO YOU IN THE NEXT FEW HOURS[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ disabled_on=”|on|on” _builder_version=”3.24″ background_image=”https://a1seniorcareadvisors.com/wp-content/uploads/2019/06/contact-us-3-1-min.jpg” inner_width_tablet=”50px” inner_max_width_tablet=”100px” inner_max_width_phone=”50px” z_index_tablet=”500″ box_shadow_horizontal_tablet=”0px” box_shadow_vertical_tablet=”0px” box_shadow_blur_tablet=”40px” box_shadow_spread_tablet=”0px”][et_pb_row _builder_version=”3.25″][et_pb_column type=”4_4″ _builder_version=”3.25″ background_color=”rgba(156,192,56,0.9)” custom_padding=”20px|20px|20px|20px” custom_padding__hover=”|||”][et_pb_text _builder_version=”3.27.4″ text_font=”Open Sans|600||on|||||” text_text_color=”#ffffff” text_font_size=”32px” text_line_height=”1em” text_orientation=”center” module_alignment=”center”]Looking For Free Advice ?
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mic1.425.324.5592

to speak with an Advisor
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maila1careadvisors@gmail.com

DROP US AN EMAIL AT ANYTIME, We WILL REPLY TO YOU IN THE NEXT FEW HOURS
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