Patient Attestation Form/Participation in the Development of the Plan of Care

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.