PO Box 1237 Edmonds, WA 98020

425-672-8787, Fax 425-670-1640

Consent to Provide Services

Client's Name:

Address:

By this document, l, give consent to Community Support Solutions to provide DDA supported CFC/MPC, RESPITE CARE and IN HOME CARE services to the following individual:

I have received the Patients Bill of Rights, the Grievance Policies and Procedures and the Advanced Directives Policy provided by Community Support Solutions. I understand that I am responsible for any charges not covered by Medicaid or Developmental Disabilities Administration.   

Client's Signature:

Relationship to Client (if not the client):  

Client Intake Completion Date:

PO Box 1237 Edmonds, WA 98020

425-672-8787, Fax 425-670<640

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Signature Certificate

Document name: Client Contracts

Unique Document ID: 7bb25f5637b338d48a7a23e813edb368fb3270d5

Build. Track. Sign Contracts.

Timestamp	Audit
April 11, 2023 10:12 pm PST	Client Contracts Uploaded by Sarah Pulliam - geauxvirtually@yahoo.com IP 70.189.63.175

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://www.businessofcare.com/

Audit Trail Serial# 23dec7526aa4a451858299a649cdd514