ROCK Authorization For Emergency Medical Treatment
Read both and select
below and sign:
: In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services or while being on the property of the agency, I authorize ROCK to 1)Secure and retain medical treatment and transportation if needed 2)Release any records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes X-ray, surgery, hospitalization, medication, and any treatment procedure deemed "life-saving" by the physicians. This provision will only be involved if the emergency contacts are unable to be reached.
: I do
give my consent for emergency medical treatment/aid in the case of illness or injury during the process or receiving services while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to be followed:
Need assistance with this form?