Release of Information

2. 

3. Release of Information

5. I

   authorize my medical records and/or documentation, past or present, to be forwarded to Portage Manor from organizations (doctors, hospitals, laboratories, etc.) that will be beneficial for my on going treatment and care.

9. The purpose of this Release of Information form is for pre-admission to a Residential Health Care Facility.

   The purpose of this Release of Information form is for pre-admission to a Residential Health Care Facility.

11. Resident Signature:

12. Date:
    Date:

14. Social Service/Designee Signature:

15. Date:
    Date:

Leave This Blank:


16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit Submit and Print

* indicates a required field