Richardton, ND Skilled Nursing Facility

To release to:
Richardton Health Center

The following information is requested:

1. History and physical that includes complete medical history, review of all body systems, specific evaluation of individual’s neurological system in all areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes. If there are abnormal findings, specialist’s evaluations are needed.

2. Comprehensive drug history.

3. The completion of the attached form: ND Level I screening and Level of Care Determination.

4. Recent medical problems/surgeries if not addressed in history and physical.

Releasor, its agents and its employees, are hereby relieved any responsibility or liability that may arise from the release of reproduction of such records and/or information.

Releasee, its agents and its employees, are hereby authorized to obtain, inspect and reproduce such records and/or information and are hereby relieved of any responsibility or liability that may arise from such actions.

This authorization to Releasor and Releasee and this waiver of liability includes, but is not limited to, charts, x-ray, photographs, motion picture films, reports, information, papers, writings, and records concerning both the patient’s physical and mental/emotion condition, whether Releasor now has same or makes or obtains them in the future.