Consent to Receive Services:
hereby, authorize the Agency to render appropriate home health services to me. I certify that I am homebound and cannot leave home, without the assistance of someone. I have been fully informed of the Agency's assessment and evaluation of my homecare needs, the risk of receiving the care, and of declining the home care services. I understand that the Agency does not do drug testing on it's employees. I accept the proposed Plan of Care and authorize services to be provided, by the Agency, in accordance with the orders of my physician, and supervision to be done, by Agency personnel. I recognize that I have the right to refuse treatment, or terminate services, at any time, by notifying the Agency office. Also, the Agency may terminate service, by notifying me, of termination and reason. I believe my service needs to be:
Authorization for Payment to Provider: I certify that information given by me, in applying for payment under title XVIII or title XIX of the Social Security ACT, or other third party pay or coverage, is correct. I authorize any holder of medical or other information, about me, to be released, to the SSA or its intermediaries, or other third-party payers any information needed for this or other related claims. I request that payment, as authorized, be made, on my behalf, to the Agency. This authorization and request shall apply to the certification period starting
until the order is discontinued, by my physician.
Charge for Services: Your initial services, from the Agency, will include the following services and initial frequency of visits and charge, per visit, if private insurance or private pay.
Services/Supplies
Skilled Nursing
Speech Therapy
Home Health Aide
Physical Therapy
Occupational Therapy
Medical Social Worker
Other
PATIENT LIABILITY FOR PAYMENT: You have the right to be advised, before care is initiated, of the extent to which payment for services my be expected, from Medicare, or other sources, and the extent to which payment may be required from you, the patient. We are advising you, orally and in writing, about the cost of items and services to be provided: Medicare part A or part B; Services provided are paid in full by Medicare. No cost to patient.
Medicare Part B Outpatient; Patient is responsible for the annual deductible and 20% co-payment for all charges for PT, ST, OT series which is
You will receive a monthly bill for charges incurred and not covered by Medicare. Medicaid: Services provided are paid, in full by
As the patient, you will be notified of any change in the charges for items or a service, provided through Medicare. Medicaid or other relevant Federal Programs as soon as possible, but no later than the next home visit. Please circle one of the following: Black Lung Veteran Administration, Worker's Compensation, or Private Insurance.
You will be responsible charges related to the services, provided to you, by this Agency. Charges related to supplies, used in providing care to you, are communicated to you, before these charges are implemented. Payment if rendered with my signature below. This assignment shall not extinguish or diminish the patient's obligation to pay the full fee, to the company for services rendered, but the patient shall receive credit for all sums collected, pursuant to the agreement. If the enrolled patient is in another insurance plan of HMO, it is the patient's responsibility to notify the Agency, or the patient will be held responsible for payment.
PATIENT'S RIGHT/EMERGENCY PLAN/COMPLAINT PROCEDURE: I have been informed of my rights and received a copy of the Client's Bill of Rights prior to the start of care procedure, "Advanced Directives, Emergency Plan, Out-of-Hospital, Do-Not-Resuscitate, Patient's Conduct & Responsibilities, Abuse/Neglect/Exploitation. " I have been allowed to participate in planning my care and have received a copy of the State's Toll-Free Home Health Agency Hotline Number for Pennsylvania, 1-800-254-5164, which receives complaints or graveness 24 hours a day, seven days a week.
CONFIDENTIALITY It is our policy to protect all clinical records against loss, defacement, tampering and use by unauthorized person(s). All patient identifiable information in the clinical record, including OASIS data remains confidential and is not released to the public. OASIS data will be electronically transmitted to the state. The patient's written consent shall be required, for the release of medical information, to persons not otherwise authorized by law (federal and state) to receive this information. Authorized persons who may review the clinical record include surveyors, physicians, Centers for Medicare and Medicaid Services (CMS) and external and internal auditing personnel.
RELEASE OF RECORDS: I understand the Agency policy, with regard to confidentiality, and release of records prohibits access to my records by persons other than personnel involved in care. I. therefore, give written consent for release of medical records to health care providers in my treatment care.
The patient has received written information regarding their right to make healthcare decisions.
