By completing this form below, I understand that Mosaic Life Care does not have to agree to a restriction. I understand that if Mosaic Life Care agrees to a restriction, Mosaic Life Care may still use and disclose my information for:

  • Emergency treatment
  • When I request to access my information
  • When I request an accounting of disclosures
  • For facility directories
  • For uses/disclosures for which consent, authorization or an opportunity to agree or object is not required.











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