Authorization for Medical Treatment and Release of Information - Geriatric Care

Patient Information

Full Name: _____________________________ Date of Birth: _______________ Medicare/Insurance #: ____________________ SSN: _______________________

Emergency Contact Information

Primary Contact: _________________________ Relationship: _______________ Phone: __________________________________ Alt. Phone: ________________

Authorization for Treatment

I, _________________________, hereby authorize [Practice Name] and its healthcare providers to provide medical evaluation and treatment to me or the named patient for whom I am legally responsible. This authorization includes:

• Physical examinations and routine diagnostic procedures
• Administration of medications and vaccines
• Laboratory tests and imaging studies
• Emergency procedures when medically necessary
• Referrals to specialists and other healthcare providers

Special Considerations for Geriatric Care

• I understand that my care may involve multiple specialists
• I authorize care coordination with other healthcare providers
• I consent to fall risk assessments and prevention measures
• I agree to medication reconciliation procedures

Release of Information

I authorize the release of medical information necessary to:

1. Process insurance claims
2. Coordinate care with other healthcare providers
3. Comply with Medicare and other regulatory requirements
4. Communicate with designated family members/caregivers

Financial Responsibility

I understand that I am responsible for all charges not covered by insurance and agree to pay any applicable copayments, deductibles, or non-covered services.

Duration and Right to Revoke

This authorization remains valid until revoked in writing. I understand I have the right to revoke this authorization at any time.

Signature: ______________________________ Date: _______________

Witness: _______________________________ Date: _______________

Healthcare Proxy (if applicable): _____________ Date: _______________