Consent Form

Authorization for Release of Information I hereby consent and authorize the Agency to release and receive information for the purposes of treatment, payment, and health care operations. The exchange of information may occur between, but is not limited to, physicians, third party payers, other health providers, and regulatory and/or accrediting reviewers.

Statement to Permit Payment for Home Health Services I hereby request that payment of authorized medical home health services be made on my behalf to the Agency.

I understand that agency will bill □ Medicare □ Medi-Cal □ Private Insurance Plan □ Patient

I understand that I will be responsible for the following amount:

Medicare/ Medicaid – home health care services are covered at 100%, no patient responsibility.

Charges per Visit

Acknowledgements I have received verbal and written information on the following, and have had the information explained to me in the format and language understandable to me: Patients’ Bill of Rights, including receipt of Agency’s discharge and transfer policies Agency’s complaint process and the state toll free hotline number. Home Health Care Patient Handbook, including Agency contact information to include contact for clinical manager, emergency and after hours. Contact information for federally and state funded entities. Notice of Agency Privacy Practices and OASIS Statement of Privacy Rights: I understand that these documents provide an explanation of the ways in which my health information may be used or disclosed by the Agency and my rights with respect to my health information. Financial charges and obligations Plan of care, including Visit schedule Medication schedule and instruction Treatments/services to be administered by Agency’s Personnel Instructions related to my care I certify that I have read and agree with the information on this document and have been provided a copy for my records.