Geriatric Care Agreement and Consent

Patient Information

Name: _________________________ Date of Birth: _________________ Medicare/Insurance #: ___________

Agreement Terms

1. Care Partnership

I, _________________________, agree to establish a geriatric care relationship with Dr. _________________________ and their healthcare team at _________________________ practice.

2. Patient Responsibilities

• Provide accurate medical history and current medication list
• Attend scheduled appointments or provide 24-hour notice for cancellations
• Follow agreed-upon treatment plans
• Inform the practice of any changes in health status
• Keep emergency contact information current
• Maintain accurate advance directives on file

3. Provider Responsibilities

• Provide comprehensive geriatric assessment and care
• Coordinate with specialists and other healthcare providers
• Maintain accurate medical records
• Respect patient autonomy and preferences
• Provide clear communication about treatment options
• Support advance care planning

4. Emergency Protocol

• For medical emergencies, call 911
• For urgent medical concerns, contact:
  • Office Hours: [PHONE NUMBER]
  • After Hours: [EMERGENCY LINE]

5. Communication Consent

I authorize the practice to communicate with me and/or my designated caregivers via:

• Phone: □ Yes □ No
• Email: □ Yes □ No
• Text: □ Yes □ No

6. Financial Agreement

• Medicare/Insurance billing procedures acknowledged
• Responsibility for copayments and deductibles understood
• Annual wellness visit scheduling agreed upon

Signatures

Patient/Legal Representative: _________________________ Date: _____________

Provider: _________________________ Date: _____________

Witness: _________________________ Date: _____________