authorization for use and disclosure of protected health information

Pennsylvania Client Admission Packet ACHC Medicare

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

You may decline to sign this authorization

I,

, hereby authorize Racheal Home Health Care Inc.(hereafter collectively refered to as “Agency’) to use

and disclose in any form or format, a copy of records concerning.

(PRINT client/patient) but only as follows.

A copy ofthis signed, dated Authorization shall be as effective as the original. Agency may use and disclose the following information

To:

For the purpose(s) of (be specific):

I specifically authorize Agency to use and disclose the following types of confidential information (initial where appropriate)

The undersigned does hereby release, hold harmless, and agree to indemnify Agency, its employees, and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this authorization. understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this authorization remains effective until Agency is in actual receipt of a signed. revocation or until the records retention period, required under federal and state law, has expired and the records have been destroyed; that have the right to revoke this authorization at any time, provided I do so, in writing; that have been given an opportunity to ask questions; that have received a copy of the signed authorization; that may inspect a copy of my protected health information to be used, or disclosed, under this authorization; that the Agency has not conditioned provision of services to, or treatment of, me upon receipt of this signed authorization; and that may refuse to sign this authorization.

Patient Signature:

Date:

OR

Patient's Representative:

Date:

(Print name and describe authority):

Agency Representative Signature & Title

Date:

Pennsylvania Client Admission Packet ACHC Medicare

patient rights and responsibilities

The Patient has the Responsibility:

1. To provide, to the best of his/her knowledge, accurate and complete information about:

a. Past and present medical histories.
b. unexpected changes in his/her condition.
c. Whether he/she understands a course of action selected.

2. To follow the treatment recommended, by the particular handling of the case.

3. For his/her actions, if he/she refused treatment, does not follow the physician’s orders.

4. To ensure that the financial obligations of his/her health care are fulfilled, as promptly as possible.

5. To respect the rights of all staff providing service.

6. To promptly notify the Agency, in advance, of an appointment or visit you must cancel.

7. To become independent in care to the extent possible utilizing self, family, and other sources.

8. To pay for care, or services, not covered by the 3rd party payers.

9. To comply with the rules and regulations established by the agency and any changes subsequent to the rules

Pennsylvania Client Admission Packet ACHC Medicare