Consent Form Print & Sign

THE PROTECTIVE SERVICE AGENCY

United States of America

CONSENT OF REPRESENTATION

UNITED STATES CODE TITLE 42.3058i PREVENTION of ELDER ABUSE ACT:

:1973 PEOPLE WITH DISABILITIES ACT – L No. 93-112, 87 STATUTE 394:

I ______________________________, legal guardian for,_________________________________:, do here by authorize the PROTECTIVE SERVICE AGENCY full access and rights to any and all information, including medical records, as entitled under the HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT, and financial assets, as may be requested by the agency pertaining to the care, safety and well being

 of,____________________________________________.

The PROTECTIVE SERVICE AGENCY has been retained to observe, visit, inquire and investigate all matters pertaining to the safety, prevention of exploitation, abuse and neglect

 of___________________________________________,

as stated by Federal, State and Local Laws under the ELDERLY ABUSE, NEGLECT and EXPLOITATION ACT.

The PROTECTIVE SERVICE AGENCY has full rights to report and enlist the services of other Governmental Agencies, Law Enforcement and Legal Authorities to enforce the laws and penalties under the ELDERLY ABUSE, NEGLECT, and EXPLOITATION ACT, and to hold those accountable to the fullest extent of the law who are in violation of such laws.

Legal Guardian Signature:______________________________________________

Date:________________

Agent:__________________________________________

Date:________________

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