I GRANT permission to the employees of Racheal Home Health Care Inc., herein referred to as "the Agency" to render skilled nursing care and other ancillary skilled professional home health services, as required and ordered, by my physician.
I ACKNOWLEDGE that the Agency has notified informed and explained, to me, the PATIENT BILL OF RIGHTS. I have
received information on Advance Directives, Directives to Physician, Durable Power of Attorney for Home Health Care, and Out of Hospital DNR orders, the services to be provided, the supervision of the services, and charges for services rendered, which will be the responsibility of the patient/family to pay.
I AUTHORIZE the Agency to release any medical information, requested by representatives of local, state or federal
agencies, accrediting bodies, insurance companies, or other organizations or entities as may be required, by said
representatives, for payment of claims, from this home healthcare, which are due. The Agency has notified me of the Policies and Procedures regarding Disclosure of Clinical Records.
I REALIZE that Agency staff may not be present in my house, at all times, and I, my caregiver, or legal guardian will assume responsibility for my care, when Agency staff is not present.
I UNDERSTAND that the Agency will notify me, and my representative (if any), in writing and orally, as soon as possible,
in advance of the next home health visit, of charges not covered by Medicare or other sources.
I UNDERSTAND that the Agency does not routinely perform drug testing on its employees but may do so, at our
discretion, using urine samples.
I UNDERSTAND that, in the event of an emergency during which the Agency cannot meet my needs, the Agency can
transfer me to another Agency that can provide the care I require.
I CERTIFY that no Medicare home health services are being provided to me and I am not enrolled to any HMO/PPO
organization.
I FURTHER UNDERSTAND that Agency employees may not be employed, by me, without first compensating the Agency
$1100.00, or employee's annual wages, whichever is greater.
INSURANCE ASSIGNMENT: In consideration of any services rendered, I hereby assign and transfer, to the Agency, any benefits payable to, or for my benefit under, the rules and regulations prescribed by Medicare. I
agree to cooperate, aid, and assist the Agency in the process of billing Medicare for these services. | certify that no Home Health Agency is currently providing home healthcare and understand the misrepresentation of this fact shall cause me to be liable financially for care, rendered by the Agency. If Home Health services provided, by another Home Health Agency in the past, I have requested discharge from those services, prior to my start of care date with this Agency. I certify the information given, by me, in applying for payment under Title XVIII of the Social Security Act, is correct. I request that Payment of Client benefits, on my behalf, are made directly to the Agency.
I HAVE BEEN INFORMED of the Agency's policies for resuscitation, medical emergencies, and accessing 911 services,
(Ems)
I AM AWARE that a Registered Nurse will be supervising my care, and if I have complaints regarding services rendered, I am to contact the RN in charge of my care.
I HAVE BEEN INFORMED of my rights that I may file complaints, about the Agency, with the Pennsylvania Home Health Hotline at 1-800-254-5164, during regular business hours. After hours/ holiday calls will be answered by machine and responded to the next business day.
