Standard Authorization Form

Person Served: *

Date:*

I, hereby, authorize A Helping Hand Senior Care Services LLC. to undertake, as identified below, the following procedures CHECKED “yes” to assist or teach me in the management of my money and benefits.

I give permission to store funds in a safe and secure place when I am not using them.

Yes

No

I give permission for employees to help to manage/budget and handle CASH ON HAND

Yes

No

I give permission for employees to help to manage/budget and handle CASH ON HAND

Yes

No

I give permission for employees to help to manage/budget and handle a SAVINGS ACCOUNT

Yes

No

I give permission for employees to help to manage and handle CHECK/ATM/CASH CARD

Yes

No

I give permission for employees to help to manage and handle GIFT CARDS

Yes

No

I give permission to help complete or complete for me, any required INCOME REPORTING

Yes

No

I give permission for A Helping Hand Senior Care Services to act as Representative Payee

Yes

No

I give permission for A Helping Hand Senior Care Services to act as Authorized Representative

Yes

No

I give permission to limit funds to a specific amount without prior approval

Yes

No

Specific information regarding the limiting of funds, including limit amount:

I give permission to store my property for safe keeping

Yes

No

Specific information regarding the property to be stored, including reason for safekeeping:

I give permission to limit cash to be carried without having to keep receipts or records

Yes

No

Pocket cash limited to:

I give permission for A Helping Hand Senior Care Services LLC to provide financial reporting upon request only

Yes

No

Note frequency of requested financial reporting:

Note itemized funds records to provide:

Cash

Checking

Savings

Gift Cards

I authorize the supervisory staff from A Helping Hand Senior Care Services LLC. to manage my services to obtain all or part of the emergency medical services as I have CHECKED below. I understand that these authorizations apply only in the event of a medical emergency and I cannot be quickly reached. I also understand that I may revoke these authorizations at any time.

Yes

No

Emergency First Aid

Lab Procedures

Emergency Surgery

Other

Please describe any limitations to the authorizations checked:

I, hereby, authorize staff trained by the program to provide medication setup and/or medication administration (prescription medications, including psychotropic medications and over the counter medications) or treatments ordered by a health care professional.

I, hereby, authorize staff trained by the program to provide medication assistance to promote self administration of medications and treatments.

I, hereby, authorize A Helping Hand Senior Care Services RN or LPN to administer injection medication(s) according to prescriber’s orders and written instructions.

I refuse to authorize staff trained by the program to administer medications (prescription and over the counter) or treatments ordered by my health care professional.

I, hereby, authorize the staff at A Helping Hand Senior Care Services LLC. to maintain and release a photograph of me for use in an emergency situation.

Yes

No

I, hereby, authorize the staff at A Helping Hand Senior Care Services LLC to videotape/audiotape and remotely supervise my activities while on A Helping Hand Senior Care Services property. Video cameras may be located in any and all common areas of the property, except bedrooms and bathrooms.

Yes

No

The A Helping Hand Senior Care Services LLC. Medal Program was designed to provide a positive and non-punitive approach to curbing maladaptive behaviors and encouraging pro-social behaviors. We must recognize that as we continue to strive to help people be successful in the community that a key part of that success hinges on positive behavior. Please check off the appropriate box below (check one box only).

I wish to participate in the Medal Program and have my name and number of safe days displayed in the common area.

I wish to participate in the Medal Program and NOT have my name and number of safe days displayed in the common area.

I do not wish to participate in the Medal Program.

I understand that I may revoke this authorization at any time or any part herein, except to the extent that action has been taken in reliance on it. All or parts of this document can be amended upon written request, at any time. In any event, this consent expires annually. I have participated in the completion of, and have been provided a completed copy of this Standard Authorizations.

Person Served*

Date:*

Legal Representative*

Date:*

Case Manager*

Date:*