PCL Rights and Responsibilities

PCL Rights and Responsibilities

Annual Rights & Responsibilities Packet

Signature Page

The following signatures indicate that the person supported and/or guardian have received and generally understand the rights & related PCL policies.

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Person Supported Name Signature Date

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Witness Name Signature Date

(*N/A if Guardian Signs)

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Guardian’s Name Signature Date

(*N/A if person does not have a guardian)

ANNUAL CONSENT FOR MEDICAL AND DENTAL CARE

& RELEASE OF INFORMATION REGARDING HEALTH STATUS

The following signatures constitute authority for Partnerships in Community Living, Inc., to proceed with medical and dental care for the person receiving residential services.

The following signatures also constitute an agreement that all medical information regarding the person and his/her condition, prognosis, etc. may be shared with his/her support team members. These team members include PCL representatives such as: Service Coordinator, Direct Support Professional, PCL RN’s, etc...

In the event of an emergency, every effort will be made to give notice and obtain consent from any parents, guardian, or person having legal custody of the person and/or the person, if applicable. In some instances, it may be impossible to secure consent quickly and the resulting delay may endanger his/her life. The signatures on this consent indicate approval for the protection of the person and authorize medical personnel to proceed should it be impossible to communicate with the person (or legal or health care representative) or in an emergency. PCL will ensure that reasonable effort has first been made to communicate with the person and any legal representative concerning the necessity of surgery and/or other medical and dental care.

Please Complete the Following ~ Signatures indicate support of consents/releases described above.

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Person Supported Name Signature Date

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Witness‘s Name Signature Date (*N/A if Guardian Signs)

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Guardian Name Signature Date

(*N/A if person does not have a guardian)

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Health Care Rep Name Signature Date

(*N/A if person does not have a Health Care Rep)

Photo/Video Consents

Consent for photographs/video - I authorize PCL to photograph/video or permit persons to photograph/video me (or the protected person if there is a guardian) while supported by PCL. I agree that the pictures/video may be used when they are deemed helpful and respectful.

Consent for use of information for PCL Newsletter or for Public Relations purposes - I authorize PCL to use non-confidential information about me (or the protected person in the case of a guardian) in brochures, public relations materials and/or the agency newsletter when they are deemed useful.

Any comments by the person supported and/or guardian regarding any of the rights policies should be noted here. Please note any exceptions to the above consents:

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This consent will remain in effect until such time a written notice is given to PCL to end.

Please Complete the Following ~ Signatures indicate support of consents/releases described above.

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Person Supported Name Signature Date

______

Witness’ Name Signature Date

(*N/A if Guardian Signs)

______

Guardian’s Name Signature Date

(*N/A if person does not have a guardian)