Authority to act on your behalf form

Authority to act on your behalf
By signing the “Authority to act on your behalf” form, you are giving Compatible Care Nursing Services consent to obtain relevant medical records, reports and/or statements from your treating medical practitioner, hospital and other relevant medical documents. The purpose of collecting this health information is to assist Compatible Care Nursing Services in finding suitable accommodation within the Aged Care Sector or care in the home. By not consenting to the collection of this information, Compatible Care Nursing Services may be unable to proceed in ensuring the correct accommodation is sourced at the appropriate care level required.
Clients Full Name*

First NameLast Name
Clients Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clients Phone Number

Area CodePhone Number
Clients Mobile
Clients E-mail
Clients Date of Birth*

DayMonthYear
Date
What is your Gender?*

MaleFemale
I,*
Name
hereby give permission for Compatible Care Nursing Services, or designated representative, to receive all required medical documents, information and personal details and the authority to discuss medical needs with relevant agencies in order to secure required care services.

This form also authorises Compatible Care Nursing Services to liaise on my behalf in the process of setting up transitional, residential or home care services required with my current health status.
Care Recipients Representative Information

If the person filling out this form is not the client, please enter your details below and attached your Enduring Power of Attorney and/or Enduring Power of Guardianship
Contact Person 1*
Contact Number*
Relationship*
Contact Person 2
Contact Number
Relationship
EOI/OPG Upload

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Enduring Power of Attorney/Enduring Power of Guardianship Cancelof
I Agree*

I have read, understood, acknowledge and confirm that the information is true and correct
Full Name*

First NameLast Name
Should be Empty:

Authority to act on your behalf

Care Recipients Representative Information