Authorization, agreement, and acknowledgements

Pennsylvania Client Admission Packet ACHC Medicare

authorization, agreement. and acknowledgements

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 does not routinely perform drug testing on its employees but may do so, at our discretion, using urine samples.

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, in the event of an emergency during which the Agency cannot meet my needs, the Agency cantransfer 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 herebyassign ang transfer, to the Agency, any benefits payable to, or my benefit underm 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. I certify that 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 discharged 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 INFROMED of the Agency’s policies for resuscitations, 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 and 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.

Client Name:

Date:

Client Signature:

Responsible Party:

Pennsylvania Client Admission Packet ACHC Medicare

Advanced directive acknowledgement/hipaa/homecare privacy rights acknowledgement

Client's Name:

Medicare HIC#

, acknowledge that the Agency has provided me with information, which indicates that I may accept, or reject, any medical treatment,

including any particular care specific:

Living Will or Out of Hospital Do Not Resuscitate (DNR)
Statutory Power of Attorney for Health Care decisions
Advance Directives in Pennsylvania – A Health Care Directive
HIPAA/Home Care Privacy Rights

I also understand that it is my responsibility to ask question about the information, provided by the Agency. They have offered to provide a copy of the state’s illustrative forms under state law if I request. I have also been advised to consult with my physician, lawyer, family, clergy, social worker, or other qualified personnel for additional information or contact with a lawyer, should I need assistance in changing the forms to reflect my treatment wished or in executing a living will or statutory Power of Attorney for healthcare decisions.

I understand that this Agency will honor the advance directives and is willing and able to provide any procedure, specified on the advance directives.

I understand that the fact that I have, or have not, signed a living will or Statutory Power of Attorney for Home Care decisions foes does not affect the medical treatment and home care to be provided, by the Agency. I understand that it is the Agency’s written policy to fully comply, through its healthcare providers with the terms of a patient’s Living Will or Statutory Power of Attorney for Healthcare decisions to fullest extent, permitted by state statutory Power of Attorney for Healthcare decisions to fullest extent permitted by state law.

I have been given an explanation. and acknowledge receipt of, the HIPAA PRIVACY RIGHTS. I understand that I may contact the Agency at any time for questions or concerns

Please check the following:

hipaa privacy rights

Patients have the right to give adequeate notice concerning the use/disclosure of their PHI on the first date of service delivery, or as soon as possible after an emergency.

The Privacy Rule grants patients’ new rights over their PHI, including the following:

Receive a Privacy Notice at the time of the first delivery of service.
Restrict use and disclosure, although the coved entity is not required to agree,
Have PHI communicated to them by alternate means and at alternate locations to protect confidentiality,
Inspect, correct and amend PHI and obtain copies, with some exceptions,
Request a history of non-routine disclosures for six years prior to request, and,
Contact designated persons regarding any privacy concerns or breach of privacy, within the facility or at HHS.

Signature Client or Representative (Signed on behalf of client when authorized to the extent permitted by state law);

Authorization, agreement, and acknowledgements

Pennsylvania Client Admission Packet ACHC Medicare