Forms: Consent for Release of Information / Appointment of Representative (08MA013E)

Consent for Release of Information and Appointment of Representative

Part 1 of the form is used by the nursing facility to secure the permission of the client, the client’s spouse, guardian or other responsible party to allow OKDHS to release all information necessary for the nursing facility to assist the client in processing the nursing home care application.

Part 2 of the form is used by the nursing facility to secure the permission of the client or other responsible person to be appointed as the client’s authorized representative.

Form 08MA013E

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