JRC Adult Day Center Release of Medical Information

JRC Adult Day Center Release of Medical Information
Member Name
Date of Birth

MonthDayYear
Date
Social Security Number
Emergency Contact
Hospital
Has applied and/or attends JRC Adult Day Center. The center requires a medical history, physical and list of medications upon admission and annually thereafter. In the event of a medical emergency JRC will pass along medical information that has been reported to them for the purpose of treatment. This information is held confidential and only used by the agency and/or staff as permissible by law.

I authorize the release of my medical information to JRC and also authorize JRC to share my medical information with other health care providers for the purpose of treating my medical emergency.
Signature of Member Spouse or Guardian

Clear
Date

MonthDayYear
Date
Should be Empty: