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 a A1 Senior Care Advisors representative to be included in care conferences and discharge planning.
Authorization to Obtain and Release
Authorization: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. 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.
Please release information to:
A1 Senior Care Advisors LLC
Address: 12520 SE 72nd St Newcastle WA 98056
Phone: 425-324-5592
Fax: 1-888-288-4999
email: a1careadvisors@gmail.com
