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 child.
Date of initial plan of care:
Name of Patient (or Parent/Guardian): November 20, 2018
Witness/KCC Staff Member: November 20, 2018
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Attestation Form
Agree & Sign