info@thomastonhospice.com
Fax number
Thomaston, GA 30286
7 Days A Week
If you have any questions, please contact us. Thank you!
I request Hospice Services from Thomaston Hospice, Inc. I acknowledge and agree to the following:
I give consent and approval for notations to be made on Hospice records and care plans concerning the medical, nursing, psychological, religious, and personal information necessary for Thomaston Hospice, Inc. to fulfill its functions.
I give consent and approval for release of information and appropriate medical records to or from any hospital, nursing home, home health/hospice agency, health organization, or physician to authorized personnel of Thomaston Hospice.
I authorize the release of any medical information, including information related to psychiatric care, drug and alcohol abuse treatment, and HIV/AIDS confidential information, necessary to process insurance claims or any medical information that is needed for utilization review or quality assurance activities.
I authorize the release of any medical related information to help in the release for visitation of any family or friends incarcerated in a penitentiary or asylum.
Upon verbal request to Thomaston Hospice Staff, I authorize the release of any medical related information to any Federal, State or local organizations in order to pursue additional emotional, financial or physical support that I might be eligible to receive.
This release is valid until discharge from Thomaston Hospice, Inc.
Patient Name *
Patient's DOB *
Today's Date *
Patient Representative *
Relationship to Patient *
Phone Number *
Witness *
We have elected to use electronic signatures as the default choice in lieu of paper. Be advised that according to the U.S. Federal E-SIGN Act in addition to various state laws an electronic signature is legally the same as a paper and ink signature.
Electronic Signature *
