N.J. Admin. Code § Tit. 15A, ch. 3, subch. 2 app A
OMBUDSPERSON DISCLOSURE CONSENT FORM
In New Jersey, persons over the age of 60 who reside in licensed facilities are fortunate to have an individual appointed by the Governor whose responsibility it is to promote, advocate and ensure the adequacy of care and quality of life you experience. This individual is the Ombudsperson for the Institutionalized Elderly. One of the Ombudsperson's roles is to investigate complaints of abuse and exploitation. Should such a complaint ever arise, this form gives you or your judicially-appointed guardian the power to authorize the release of any findings of any investigation of this nature to the person(s) you or your guardian choose.
In the event of an investigation by the Ombudsperson relating to my care, I hereby authorize the Ombudsperson to release the results of such an investigation to the following person(s):
| (1) | Name: ______________________________ |
| Address: ______________________________ | |
| ______________________________ | |
| ______________________________ | |
| Telephone: ______________________________ | |
| (2) | Name: ______________________________ |
| Address: ______________________________ | |
| ______________________________ | |
| ______________________________ | |
| Telephone: ______________________________ |
The Ombudsperson shall not be required to disclose the results of any investigation to any person other than me, a guardian appointed for me by a Court, a duly authorized holder of a power of attorney for health care, or the person(s) named on this consent form.
Signed: _______________________ Date: ________________________
Witness: ___________________________________________________
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Note: This form is to be completed ONLY by the resident or a judicially-appointed guardian of the person of the resident. Neither a "responsible" party nor a holder of the resident's financial power of attorney has the legal authority to complete this form.
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N.J. Admin. Code Tit. 15A, ch. 3, subch. 2 app A