Patient Attestation Patient Attestation Patient AttestationPatient / Dependent Name(Required) I verify that I have participated in the development of the plan of care with my service provider, and that the plan of care is based upon my unique need and circumstances, as reported. I understand that an interdisciplinary team approach will be utilized for the achievement of this plan of care when warranted. In signing this attestation, I declare that my views and choices have been considered in the plan of care development. For children: As parent/guardian of the child specified above, I give permission for collateral services on behalf of my child.I verify that I have participated in the development of the plan of care with my service provider, and that the plan of care is based upon my unique need and circumstances, as reported. I understand that an interdisciplinary team approach will be utilized for the achievement of this plan of care when warranted. In signing this attestation, I declare that my views and choices have been considered in the plan of care development. For children: As parent/guardian of the child specified above, I give permission for collateral services on behalf of my child.Date of initial plan of Care:(Required) MM slash DD slash YYYY (Signature of client/parent/Guardian)(Required) Reset signature Signature locked. Reset to sign again Today’s Date(Required) MM slash DD slash YYYY