Patient Acknowledges - Receipt of Patient Information Booklet

Patient Name:

MR#:

have received the following information from the Representative of Racheal Home Health Care Inc. prior to the beginning of care:

Patient Information Booklet, which includes:

1. Service Outline
2. Emergency Contact information
3. Non-Discrimination Polices
4. Patient Rights and Responsibilities
5. Patient Grievance
6. Abuse, Neglect, and Exploitation; Abuse and State Hotline numbers
7. Home Health Aide Duties
8. Accident Prevention
9. Notice of Privacy/Privacy Act Statement
10. Medication Information
11. Fire Safety
12. Biomedical Waste Disposal
13. Emergency Instructions, Resource numbers, and Disaster Preparedness
14. Advance Directive Information Summary
15. Patient Privacy Rights/HIPAA

Note: Please indicate person approved to receive information regarding care and medical information:

Note: Please indicate person approved to receive information regarding payment for care:

Patient Signature:

Date:

Witness Signature:

Date:

G. OPTIONS. Check only one box. We cannot choose a box for you.

What You Need To Know

Option 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

Option 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

Option 3. I don't want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

Read this notice, so you can make an informed decision about your care.

1. Ask us any questions that may have after you finish reading.
2. Choose an option below about whether to receive the D. listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

H. Additional Information:

This notice gives your opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048)

Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature

J. Date

Phone

This field is for validation purposes and should be left unchanged.

Patient Acknowledges - Receipt of Patient Information Booklet

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Patient Acknowledges - Receipt of Patient Information Booklet

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