Family consent to be contacted (form for professionals)
A one-page form a family signs so a case manager can share their contact information with Novita Way. No medical information.
I agree that the professional named below may share my name and phone number with Novita Way so that Novita Way can contact me about senior living options. I understand Novita Way is free to families, and I can say no at any time. No medical records are shared through this form.
Family member name: ____________________________________________
Phone: ____________________________________________
Best time to call: ____________________________________________
Relationship to the person needing care: ____________________________________________
Signature and date: ____________________________________________
Professional name, organization and phone: ____________________________________________
Send to Novita Way: call (727) 632-8291 or use the referral form at novitaway.com/professionals/. Keep the signed copy in your records.
General information only, not medical, legal or financial advice. Programs and amounts change; confirm with the official source or a qualified professional.