Disclosure Statement | Washington — Family Values Adult Placement Agency

Name of Client/Client's Representative *

The name of clients POA/Alternate decision maker

Email *

Phone Number *

Disclosure Statement Read *

I have read the disclosure statement outlining the senior care consulting services provided by Family Values Adult Placement Agency.

Information Disclosure *

I authorize Family Values Adult Placement Agency to obtain confidential health care information and disclose it to health care providers. The agency will not require or request clients to sign waivers of potential liability for losses of personal property or injury, or to sign waivers of any rights of the client established in state or federal law.

Electronic Signature *

Additional comments

Disclosure Statement | Washington