Questions? Please call 800-361-0138 any day of the week from 8:30AM to 8:30PM Pacific Time

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To comply with the Elder & Vulnerable Adult Referral Agency Act of April, 2011. Last updated: Nov 1, 2013

1st CHOICE Advisory Services, Inc. - Disclosure Statement and Information Release Form
[Client direction regarding the release of private health care information]

To view the entire document, please click on "Expand to show complete document."

We are grateful if you would please confirm receipt of this document now by placing check marks in the two sections at the bottom of this form and then click on "Submit".

If you prefer, you can click on "Download as PDF" to read and print out the entire document. If you choose this less automatic method of confirming with us, you can then print out the form and sign and either 1) scan and send the completed document to bestcare@choiceadvisory.com or 2) fax the signature page to our toll-free fax of 800-206-6910.

Your Reference Number:
Your Housing & Care Advisor:
Your Advisor's Cell Phone Number:
Main Office Number:	800-361-0138

Any concerns you have may be reported to Officers at 1st CHOICE Advisory Services, Inc.
Clint Slater, President, Director of Business Services 800-361-0138 or clint@choiceadvisory.com
Les Ostermeier, VP, Director of Development 800-361-0138 or les@choiceadvisory.com

© Copyright 2015, 1st CHOICE Advisory Services, Inc. All Rights Reserved.

Download as PDF   Expand to show complete document

Housing and care advisor you are working with:	--- Please select a housing and care advisor --- I do not know Beth Slaughter Casey Crum Christyna Hengstler Daniel Thal Danielle Ionesi Deirdre Bulmann Dorinda Wheelock Gay McDonald Jen Johnston JJ Koll Joni Moore Julie Ouellette Kay Loeffl Les Ostermeier Liz Murray MK Gropper Naomi Slater Shari Levelle Shayla Smith Sue Frisbee Sylvia Meckem Terry Fontaine
Your name:
Your phone number:
Your email address:
Name of older adult 1:
Name of older adult 2:

I confirm receipt of the Disclosure Statement & Information Release Form of 1st CHOICE Advisory Services, Inc. contained in this document. Also, I verify that I am either the older adult seeking assistance or I am a family member or related to the older adult OR, I hold legal documents such as Power of Attorney or Guardianship to help the older adult(s).

By checking this box and completing this form you are confirming receipt of the above documents. Additionally, you are confirming that 1st CHOICE Advisory Services, Inc. as well as representatives and associates of the agency are given permission to discuss your potential interest in them; or that the agency has permission to communicate with potential providers on your behalf.

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Questions? Please call 800-361-0138 any day of the week from 8:30AM to 8:30PM Pacific Time