Authorization for Release of Protected Healthcare Information
License: 603 261 405
Graham & Graham LLC is an Eldercare Referral Agency
- I have chosen Graham & Graham Eldercare Consultants as my Care Transitions Consultant/Coordinator and Healthcare Advocate.
- I request that a Graham & Graham Eldercare Consultant be included in care conferences, and planning for my safe discharge. Their representation includes placement, if needed. Contact information for Graham & Graham LLC is:
- I authorize the disclosure and release of protected health information from any of my health care providers, their employees, and agents. My release authorization includes my complete health record including diagnosis, medical records, status, examination, medications, treatments rendered to me and claims information. This information may be released to:
- Any Staff Member/Agent of Graham & Graham Eldercare Consultants
- Potential care providers including Home Care/Home Health Providers, Assisted Living Facilities, Memory Care Facilities, Residential Care Homes, Skilled Nursing Facilities, Physicians and Caregivers.
- This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, selection and placement of care facilities and/or providers, or other purposes.
- This authorization for release of information covers the period of healthcare for a period of one year.
- This authorization shall be in force for a period of one year until/unless I terminate it in writing prior to one year from the date signed.
- I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.
- I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient to others specifically involved in my care planning process.