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Medical Release Form – Beyond Success Adultcare Referrals

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Medical Release Form



I hereby request and authorize Beyond Success Adultcare  to receive copies of my Medical Records and or Health Information including medical history, diagnosis, medication lists and chart notes. I give permission for Beyond Success Adultcare permission to speak with my health care representatives on my behalf to gather information that relates and pertains to my long-term care. I also ask that a Beyond Success Adultcare representative to be included in care conferences and discharge planning.

Authorization: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand I can refuse to sign this authorization. I understand that I will receive a copy of this form after I sign it. I understand that I can revoke my authorization at any time in writing. Revocation will be effective immediately when received in writing by the Source Releasing the Information and A1 Senior Care Advisors LLC.  I understand that the revocation will not apply to information that has already been released in response to this authorization. Without a revocation request this signed authorization will stay in effect until the needs for disclosure are satisfied. I have read this form, or it has been read and explained to me, and I understand its content.