Official Site of The State of New Jersey

Ombudsman Disclosure Consent Form

N.J.A.C. 17:41 Appx. A Appendix (2015)
Appendix A

Ombudsman Disclosure Consent Form
In New Jersey, persons 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 State Long-Term Care Ombudsman.  One of the Ombudsman’s role 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 investigating of this nature to the person (s) you or your guardian choose.
                                   
In the event of an investigation by the Ombudsman relating to my care, I hereby authorize the Ombudsman to release the results of such an investigation to the following person(s):

1)        Name:     __________________________________________________________
            Address: __________________________________________________________
                             __________________________________________________________
            Phone: ________‐________‐__________________

(2)        Name:     __________________________________________________________
            Address: __________________________________________________________
                             __________________________________________________________
            Phone: ________‐________‐__________________

The Ombudsman 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:          ____________________________

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 legal authority to complete this form.