Nursing Home Authorization Form

This form grants [Your Company Name] the authorization to provide care and make necessary decisions regarding the health and welfare of the resident named below. Accurate completion is essential for ensuring that we can offer the best possible care tailored to the resident's needs.

Resident Information	Full Name
	Date of Birth	[MM-DD-YYYY]
	Social Security Number
	Admission Date	[MM-DD-YYYY]
Emergency Contact	Primary Contact Name
	Relationship to Resident
	Contact Number
	Secondary Contact Name
	Relationship to Resident
	Contact Number
Medical Authorization	General Practitioner
	GP Contact Number
	Preferred Hospital
	Health Insurance Provider
	Policy Number
Care Preferences	Dietary Restrictions
	Mobility Assistance Needed
	Special Care Instructions
Legal Authorization	Power of Attorney
	POA Contact Number
	Living Will Available?	Yes/No
	DNR Order?	Yes/No

Acknowledgment

Signature of Resident (if able)

Date: [MM-DD-YYYY]

Signature of Legal Guardian/POA

Date: [MM-DD-YYYY]

This Nursing Home Authorization Form is a binding document that ensures [Your Nursing Home Name] is fully informed of and authorized to execute the care preferences and medical needs of the resident. It is imperative that all information provided is accurate and that any changes to this information are communicated promptly to the nursing home administration.