I would like to be a participant in Aurora Adult Day Program. I have received an explanation of the services that will be provided to me, a facility tour, and understand that I have the right to participate in activities of my choosing.
I hereby consent and authorize the Agency to release and receive information for the purposes of treatment, payment, and health care operations. The exchange of information may occur between, but is not limited to, physicians, third party payers, other health providers, and regulatory and/or accrediting reviewers
I hereby request that payment of authorized adult day program services be made on my behalf to the Agency.
I have received verbal and written information on the following, and have had the information explained to me:
I certify that I have read and agree with the information on this document and have been provided a copy for my records. I have participated in the formation of my plan of care.