Covering Hands Home Care – Intake + Authorization Form

Covering Hands Home Care, LLC
2323 S 109th St Suite 200A, Milwaukee, WI 53227
Hours: 9-5 M-F
(414) 249-4152 (Land Line)
(414) 292-7625 (Cell Phone)
Fax: (414) 252-0018
Authorization to Release Health Care Information
Patient’s Name

First NameLast Name
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I request and authorize the following provider/facility to release my health care information to: Covering Hands Home Care, LLC
Primary Physician/Provider
Information needed:
Others
Definition: Sexually transmitted Disease (STD) as defined by law, RCW 70.24 et seq, includes herpes, herpes simplex, human papilloma virus, wart, genital warts, condyloma, chlamydia, non-specific urethritis, syphilis, VORL, chancroid, lymphogranuloma venereuem, HIV, AIDS and gonorrhea.
Please circle the following if you agree or disagree
I authorize the release of any STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above, and anyone who may be in contact with me during my care. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone other than my caregiver.
I authorize the release of any records regarding drugs, alcohol, or mental health treatmentsto the person(s) above.
I authorize the release of my record to be shared with all my caregiver(s).
I have been informed of my confidentiality and privacy rights and understand that my signature below is
an indication of my acknowledgement to authorize the release of nay treatment, care, or medical
information related to my health to Covering Hands Home Care, LLC.

I also understand that this authorization has no expiration date as long as I am still a client of Covering
Hands Home Care, LLC and continue to receive services from Covering Hands Home Care, LLC. This
authorization is made freely and voluntarily by me and valid unless otherwise within written notice.
Client Signature
Date

MonthDayYear
Date
Intake Form
Primary Care Physician
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Authorization to Release Health Care Information

Intake Form

Primary Care Physician