Client Identification Form | Golden Grace Health Care LLC

Section A: Client Information

This form is used to collect essential identification and responsible party information for new clients. All information is maintained in accordance with HIPAA and applicable Georgia Department of Community Health regulations.

Client Full Name *Date of BirthResidential Address (Street, City, State, ZIP) *Mailing Address (if different)Primary Telephone Number *Alternate Telephone Number

Section B: Responsible Party / Legal Representative

Responsible Party NameRelationship to ClientAddress (Street, City, State, ZIP)Primary Telephone NumberAlternate Telephone NumberEmail Address

Section C: Emergency Contact (if different)

Emergency Contact NameRelationship to ClientTelephone Number

Section D: Acknowledgment

I certify that the information provided above is accurate and complete. I authorize Golden Grace Health Care LLC to use this information for service coordination, emergency contact, billing, and regulatory compliance purposes.

I certify the statement above

Signature *

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.

DatePrinted Name *