GrowthArc Authority to Release

GrowthArc Authority to Release

Please complete the form using the fields shown. Fields are optional unless the document clearly requires them.
Client Details
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number (Client)
Please enter a valid phone number.Format: (000) 000-0000.
Email (Client)
example@example.com
Authorised Representative Details
Authorised Representative's Full Name

First NameMiddle NameLast Name
Relationship to Client
Phone Number (Authorised Representative)
Please enter a valid phone number.Format: (000) 000-0000.
Email (Authorised Representative)
example@example.com
Legal Authority
Approved Providers
Approved Provider 1
Approved Provider 2
Approved Provider 3
Approved Provider 4
Approved Provider 5
Approved Provider 6
Areas of Communication & Support
Medical appointments or healthcare coordination
Hospital discharge or recovery support
Workplace or employment-related support
NDIS or disability support coordination
Wellbeing or allied health support
Aged care or accommodation support
Family or support network coordination
Administrative or life management support
Other (Areas of Communication & Support)
Authority Duration and Signatures
Ongoing until withdrawn in writing
Valid until

MonthDayYear
Date
Client Signature
Client Signature Date

MonthDayYear
Date
Representative Signature (if applicable)
Representative Signature Date

MonthDayYear
Date
GrowthArc Care Concierge Name
GrowthArc Care Concierge Signature
GrowthArc Care Concierge Date

MonthDayYear
Date
Should be Empty:

GrowthArc Authority to Release

Client Details

Authorised Representative Details

Approved Providers

Areas of Communication & Support

Authority Duration and Signatures