Secure Form

Alzheimer’s Association Illinois Chapter

Name of person being referred (patient):

Zip Code:

Name of person being contacted (if not the person being referred):

Zip Code:

Relationship to person being referred:

Self

Spouse/Partner

Son/Daughter

Grandchild

Niece/Nephew

Friend

Other (specify)

Preferred Phone:

Primary language (if other than English):

I give permission to my healthcare or service provider to fax or e-mail our name and contact information to the Alzheimer’s Association. I understand that an Alzheimer’s Association Helpline representative will contact me about support and educational opportunities. In addition to giving my permission to be contacted by the Alzheimer’s Association, I give permission for the Alzheimer’s Association to share a summary of our discussion with the referring provider as indicated below. I understand this is a free service provided by the Alzheimer’s Association. I understand that our name, contact information or health information listed above will not be disclosed or shared with any other entity unless authorization is obtained by me.

Signature:

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Date

The person being referred provided verbal consent instead of their signature:

May we identify ourselves as the Alzheimer’s Association when we call?

Yes No

May we leave a voicemail message?

Yes No

To be completed by the healthcare professional:

Healthcare provider name:

Healthcare provider organization and department:

Healthcare provider email:

Healthcare provider fax number:

Zip Code:

Additional comments (optional):

Alzheimer’s Association Illinois Chapter

24/7 Helpline 800-272-3900 | alz.org/illinois

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