Haven Senior Care Advising and Authorization Form

Haven Senior Care Advising and Authorization Form

Please complete the client, care, authorization, referral, checklist, and signature sections.
Client Information
Client Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Care Situation
Current location

Other
Primary concerns
Notes / goals
Authorization & Service Agreement
Communication Authorization
Family/Care Partner
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred communication
HIPAA Authorization
I authorize healthcare providers, facilities, insurers, community agencies, and related organizations to disclose protected health information relevant to care coordination and navigation services to Haven Healthcare Staffing and Care Navigation Services.
Information that may be disclosed
Authorization expires
Service Agreement & Signatures
Service Agreement Acknowledgement
Haven may provide senior care advising, discharge support, community resource coordination, senior living guidance, and care transition support. Haven does not provide medical diagnosis, legal advice, financial advice, or emergency medical services.

I acknowledge and agree to the service terms described above.
Referral Source / Organization
Referring Contact
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Referral Type
Internal Intake Checklist
Signatures
Client Signature
Date

MonthDayYear
Authorized Representative
Relationship
Haven Representative
Client Information Acknowledgement
By signing, I authorize Haven Healthcare Staffing and Care Navigation Services to communicate with approved, providers, facilities, agencies, and care partners for the purpose of care planning, resource coordination, referral support, and related senior care advising services.
Should be Empty:

Haven Senior Care Advising and Authorization Form

Client Information

Current Care Situation

Authorization & Service Agreement

Communication Authorization

HIPAA Authorization

Service Agreement & Signatures

Service Agreement Acknowledgement

Signatures

Client Information Acknowledgement