2. 
3. Privacy Confidentiality Form
5. I have read and agree to comply with the terms of the Confidentiality statements and will read and comply with the Portage Manor Privacy Confidentiality of Protected Health Information (PHI) and Information Security Policies, as applicable, copies of which will be provided upon request.
   Portage Manor Licensed Residential Care Facility Programs & Affiliation:
7. Check one box

   1. Employee
   2. Contract Employee
9. Check one box

   1. Medical Staff
   2. Resident

   1. Referring Physician
   2. Student

   1. Other Providers
   2. Volunteer
11. Vendor
12. Other
16. Name:
17. Last 4 Digits of SSN:
19. Signature
20. Date:
    Date:
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

* indicates a required field