I hereby voluntarily give my consent to the Caregiver and authorize him or her to care for me or my Loved one, for the period indicated below, in order to provide Homecare, as stated in the Care Plan. The Caregiver will (Contact me first for direction if applicable, and if unavailable, will) arrange for emergency medical care and treatment to preserve the health of myself (or my Loved One), if so required, for the duration of their Visit. I acknowledge that I am the responsible party for all the charges related to all Homecare and Services during the time period stated.
The purpose of this consent is to give the Caregiver the power and authority to handle my, (or my Loved one), Homecare needs as set out in the Care Plan. This consent will remain in effect until the end of the time period, or until which time the Craegiver is dismissed for the day or it is revoked. Any question, concern, or problem regarding this authorization can be directed to me by phone or email as stated under the "Contact Details" section of this consent form.