Parent/Guardian Consent to Release Plan of Care

Parent/Guardian Consent to Release Plan of Care

Authorize Accucare Nursing to share your child’s Plan of Care with a named third party for a specific purpose.
Patient Information
Patient full name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Accucare patient/record ID
Parent / Legal Guardian Information
Parent / Legal Guardian Full Name

First NameMiddle NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Recipient Information
Name of Authorized Recipient
Organization Type
Recipient Phone
Please enter a valid phone number.Format: (000) 000-0000.
Recipient Email
example@example.com
Recipient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Scope of Authorization
Documents to Release

Other
If Other, specify document
Authorization Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expiration note
Release scope note
Rights and Signature
Acknowledgements
Parent/Guardian E-Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness Name

First NameMiddle NameLast Name
Witness Signature
Witness Attestation
Should be Empty: