Consent for Medication Management Services
Name: Date of Birth:
Entry & Assessment
Plan for Treatment
Release of Information
Legal Proceedings and Release of Records
Access to Records
Potential Side Effects
Appointment Cancellation or Late Arrival:
Third Party Payer:
Information Provided at Medication Management Evaluation:
CFD provides services to all individuals who are eligible regardless of race, ethnicity, gender, gender identity, gender presentation, sexual orientation, religion, creed, national origin, age, marital status, disability, or other factors prohibited by law or regulation, except when program eligibility is restricted to children, adults, or older adults, familial status, marital status, source of income, and disability.
My signature affirms that I have read and understand this form and have had the opportunity to ask questions.
This document is being signed by: ClientPersonal Representative, see below
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent for Medication Management Services
Agree & Sign