M.I.R.A. Form – Senior Living Advisors Ltd.

Senior Living Advisors, Ltd. Agreement and Release of Health Information

I am currently working with Senior Living Advisors, Ltd. for the sole purpose of identifying senior living options. My Advisor will provide guidance to me and my family while choosing an appropriate living arrangement. The service is provided to me free of charge. I understand my Advisor will suggest viable options to me but the final decision is mine. I declare that I have the authority to engage Senior Living Advisors, Ltd. in this agreement by virtue of my title (choose one):
Title*
- Self
- Spouse
- Power of Attorney
- Legal Guardian
- Family Member
- Case Manager
- Other Legal Agent
Identify

If you choose Family Member or Legal Guardian please identify your title.
In addition, by returning this form and with my signature below, I authorize any hospital, physician or any other medical person who has attended to or examined me, the patient named below, to furnish any and all information to Senior Living Advisors, Ltd. with respect to any illness, injury, medical history, consultation, prescription or treatment and copies of all hospital and medical records. This consent will expire sixty days past the date entered below.
Date*
MM slash DD slash YYYY
Patient's Name*
Please provide the patient's name you are requesting medical records:
First Last
Patient’s Date of Birth*
MM slash DD slash YYYY

Please provide the patient's date of birth you are requesting medical records for:
I Accept:*
Please check if you accept and type your signature below:
- I Accept
Signature*
Please type your name into the field. This will be your signature.
Contact Email Address:*
Please provide an email address so we can contact you:
Doctor's Name:*
Please provide the Doctor's name providing care:
First Last
Doctor's Phone Number
Please provide the Doctor's phone number:
CAPTCHA
Specific Information Typically Requested:
- Most recent history & physical
- Most recent lab work
- Most recent chest x-ray
- Most recent medication list
- Demographic information
- Date of last flu vaccine
- Date of last Pneumococcal vaccine
Comments
This field is for validation purposes and should be left unchanged.