Disclosure Statement and Information Release Form

All clients of CareWise must sign our disclosure statement and information release form.

Please Read and Sign the Disclosure Form Below

 

ASSISTED LIVING FINDERS, LLC doing business as CareWise
Disclosure Statement and Information Release Form

This document is to define the services provided by CareWise. To best represent the interests of the older adult and/or responsible party, “Client,” and to comply with the requirements of the state of Arizona, CareWise must receive the Client’s confirmation of receipt of this information and will serve as acceptance of services in order that CareWise may be of assistance for you.

About CareWise: CareWise is dedicated to provide help for older adults with transitioning to housing and care providers. CareWise obtains personal information about older adults through its intake process, which helps to identify needs, interests and preferences of the Client. Based on this intake, CareWise provides housing and care provisions that will be of interest to the older adult and/or responsible party. CareWise provides the support to help older adults move or to encourage them to transition into new living conditions.

CareWise manages the specific information about senior residencies and care providers, “Providers,” A list of questions, known as the intake process, helps CareWise define the best geographic locations, style of life, personality and ambiance preferences, pricing and potential services for care.

CareWise can suggest referrals to Clients for legal counsel, financial advisors, health care therapies, real estate, moving services or other types of services. No financial compensation is received by CareWise for these referrals. However, the Client must apply due diligence of a Consumer. CareWise does not warrant or guarantee the quality or performance of such services. CareWise is held harmless for any loss, injury or harm that may result of using such services. It is the responsibility of the Client to determine their own personal choices regarding using such services.

Arizona Statute Requires that we provide you with the following diclosure notices

We are in the business of referrign residents to assisted living facilities and assisted living homes.  We will be paid by the facility or home if you move into one of the referred facilities or homes.  The fee we receive from the facility or home into which you move typically ranges from (0) to (100) percent of your first months rent and care charges.  We do not have a current business relationship and we do not have common ownership or control in, or any other financial, business, management or familial relationship with, any of the home or facilities to which we are referring to you.

By providing us with a written or electronic notice, you have the right to terminate our services to you at any time, including our use of your personal information.  If you terminate our services we will not be entitled to any fee for any move-in you make after the date of the termination notice unless either:

1.  The facility or home you choose within the next twelve months is one that we specifically identify and refer to you after we evaluate your profile and requests but before we receive your notice of termination.

2.  You communicate with us before you move into the facility or home.

Authorization granted to CareWise and permission to release information

Pursuant to the requirement of the Health Insurance Portability and Accountability Act (HIPAA), the purpose of this disclosure, at this time, is for both non-medical and for medical purposes. Additionally, there is the potential for the protected health information to be re-disclosed by the recipient and thus, no longer is protected under this Privacy Rule.

I understand that this consent may be revoked in writing at any time with the exception and to the extent that disclosure of information may have already occurred prior to the receipt of revocation.

I give CareWise, its employees, and its independent contractor(s) permission to access information regarding the older adult(s) named below. I also give permission to the Providers working with CareWise(physicians, clinicians, ARNPs, licensed assessors, senior residency and care providers and/or paraprofessionals such as Certified Nursing Assistants, as well as regulatory or vulnerable adult advocacy organizations) to access this information as it relates to the Client’s interest in arranging for in-come care or relocating to a senior residence or care services.