Referral and Placement Intake Form

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.