Page 39 - Home Health Marketing

I acknowledge of my rights and responsibilities as a
patient (including OASIS rights, agency administrator’s name and contact information, agency discharge, transfer and referral policy and
how to contact local resources) and I understand them. The state home health hotline number, its purpose and hours of operation have been
provided and explained to me. I acknowledge that I have chosen this agency to provide home health care. No employee of this agency has
solicited or coerced my decision in selecting a home health agency.

procedures and treatments as prescribed by my physician for the delivery of home health care. I understand that the agency will supervise
services provided, I may refuse treatment or terminate services at any time, and the agency may terminate their services to me as explained in
SAMPLE
my orientation. I agree and consent to the home care plan and payment as outlined in this admission booklet. I understand that this is the
initial plan of care. I will be notified by the agency in advance each time there is a change made to my plan of care. The initial service(s) and
visit frequencies are as follows:
Ins. Pays
Service Frequency Charges I Pay Service Frequency Ins. Pays I Pay
Charges
Skilled Nursing $ Occupational Therapy $
Physical Therapy $ Medical Social Svcs. $
Speech Therapy $ Home Health Aide $

Co-Payment: $ ________________ Deductible: $ ________________

and voice concerns. I understand that the agency may use or disclose protected health information (PHI) about me to carry out treatment,
payment or health care operations. The agency may release information to or receive information from insurance companies, health plans,
Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of my bill for
services; any person or entity affiliated with or representing for purposes of administration, billing and quality and risk management; any
hospital, nursing home or other health care facility to which I may be/have been admitted; any assisted living or personal care facility of which
I am a resident; any physician providing my care; family members and other caregivers who are part of my plan of care; licensing and
Ó MedForms, Inc. 2024
accrediting bodies, other health care providers in order to initiate treatment.
I agree that the agency may share my PHI with emergency officials or others involved in my care to assist in disaster relief efforts. o Yes o No
I certify that the information given by me in applying for payment under Title XVIII of the Social
Security Act is correct. I consent to the release of all records required to act on this request. I request that payment of authorized benefits from
Medicare, Medicaid or other responsible payer be made in my behalf to Agency Name .
If I have Medicare Part A benefits, I understand that Medicare payments will be accepted as payment in full and I have no financial liability, unless
I have been notified in writing that service(s) will not be covered by Medicare and wish to receive the care or service. I understand that while I am
under the agency’s plan of care, the agency will coordinate all medically necessary therapy services and medical supplies for me. If I arrange for
these services or supplies on my own, I understand that Medicare will not reimburse me or my supplier and I will be responsible for the total cost.
If I have other insurance, I may be responsible for the co-payment and any charges that my insurance will not cover. I will refer to the rates for
service provided above for the maximum dollar amounts that I may be required to pay. I understand that I am responsible for all amounts not
paid by my insurance. If I am a Private Pay patient, I agree to pay for all services rendered by the agency.

use the photographs/recordings for their internal use, for documenting my medical condition or for insurance providers to document my
condition for payment purposes.

I may express my wishes in a document called an Advance Directive so that my wishes may be known when I am unable to speak for myself.
1. I have made a Living Will. o No o Yes (If yes, provide a copy to the agency.)
2. I have made a Durable Power of Attorney for Health Care. o No o Yes (If yes, write the name and phone number of the person
given power of attorney.) __________________________________________________________________________________________
3. I have a Do Not Resuscitate (DNR) Order. o No o Yes (If yes, provide a copy to the agency.)

By signing this consent, I acknowledge receipt of the admission booklet and confirm my understanding and agreement with its
contents. I understand a copy of this consent shall be as valid as the original and shall remain in effect until I am discharged
from the agency. I also understand that I may revoke this consent in writing at any time.

Patient Signature Date/Time Responsible Person, Legal Representative or Legal Guardian Signature

Agency Representative Signature/Title Date/Time Printed Name and Relationship of Person Above
¨ Patient unable to sign due to: _____________________________________________________________________ ©1994-2024