Care Survey Submission Agreement2017-06-05T19:47:10+00:00

Care Survey Submission Agreement

Release of Information

I acknowledge that by submitting the Harmony Care Survey I am authorizing Harmony Senior Living Advisors to release my personal health information collected in the care survey to any discussed providers in coordination of my transitional care needs. I also hereby authorize Harmony Senior living Advisors to receive any personal health information by my providers for the purpose of helping me and my transitional care needs. I understand that any personal health information or other information released to discussed providers may be subject to re-disclosure by their organization and may no longer be protected by applicable federal and state privacy laws.

This authorization is valid from the date of submission and shall expire 60 days from my admission to the senior living option of my choosing, or one (1) year from the submission date.

I understand that I have a right to revoke this authorization by providing written notice to Harmony Senior Living Advisors. However, this authorization may not be revoked if Harmony Senior Living Advisors has already taken action on this authorization prior to receiving my written notice and will only apply from that point forward. I also understand that I have a right to have a copy of this authorization.

I further understand that this authorization is voluntary and that I may refuse to agree to this authorization.