The witnessed signature on page 6 of the application shall have the effect of:

1. (a) Confirming that the signer gives his or her permission for the medical providers and institutions indicated to:

   1. (1) Furnish to the home a copy of the applicant’s medical record;
   2. (2) Allow the home to review the medical record; and
   3. (3) Furnish to the home specified additional pieces of information;
2. (b) Confirming that the permission is for the specific purpose of consideration for admission to the home, and, if the applicant is admitted, for the specific purpose of continued care;
3. (c) Confirming that the information is confidential shall be used only for the purposes stated, and shall not be re-released;
4. (d) Requesting that the permission given by the applicant become invalid one year from the date of his or her signature; and
5. (e) Confirming the applicant’s understanding that his or her permission is subject to revocation at any time unless action on the permission has already begun in good faith.

Source. #8953, eff 7-21-07, EXPIRED: 7-21-15 New. #12564, INTERIM, eff 6-28-18, EXPIRED: 12-26-18 New. #12712, eff 1-15-19