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:

• 1. Participant Handbook Facility rules
• 2. Emergency Preparedness, Infection Control and Safety Education
• 3. Facility Tour
• 4. Orientation to policy and procedures

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.