, his/her assistants and/or designees. I am aware that the services provided by a geriatric care manager are not an exact science and I acknowledge that no guarantees have been made as to the result of evaluation or treatment.
I am aware that I am an active participant in the geriatric care management process. My responsibilities in treatment include informing my geriatric care manager of any information that may be relevant to the problems or conditions being addressed, assisting with the development of a care plan, following my geriatric care manager’s advice to the best of my ability, and ending my relationship with my geriatric care manager in a responsible way.
If I am consenting to treatment for another person, I certify that I am legally responsible for that person and am entitled to consent to treatment for them.
This form has been fully explained to me and I certify that I understand its contents. I also understand that it is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this form fully.