49 North Airmont Rd, Montebello NY 10901 Phone: 845-425-6555; Fax: 845-425-9035

Patient Name: DOB: AGE: TIME: SOC Date:

PT Address: Emergency Contact Name: Phone #:

Physician Name: Phone #:

CONSENT FOR SERVICE

CONSENT FOR SERVICES/ RELEASE OF RECORDS

I, , have been informed that Community Health Care is my primary, home health agency and is licensed to provide home health services under a Plan of Care authorized by my physician. I accept treatment from Community Health Care and can call the Agency 24 hours a day regarding my health care at 845-425-6555. This is not an emergency line. Call 911 in an emergency. It is the policy of the Agency to protect all clinical records against loss, defacement, tampering and used by un authorized persons. I authorize any holder of medical or other information about me to be released to third party payors for the purposes of managing my care and so they can process claims on my behalf.

FINANCIAL AUTHORIZATION

I authorize benefits to be paid in my behalf.

Bill primary Insurance: % Insurance Co:

Bill Secondary Insurance:% Insurance Co:

Bill Patient: Co-Payment Payment of

Per Visit Per Hr Per Weekend Live-in Holiday

Security deposit  (2 weeks) of:


I am responsible to inform the Agency of any changes regarding my insurance.

I will pay any service or supply charge not reimbursed by my insurance company on a weekly basis. I will pay all charges incurred on a weekly basis if I do not have insurance coverage. If a claim is denied for home health services which the Agency has submitted on my behalf, I hereby elect not to appeal the denial myself, but I do hereby authorize the Agency to resubmit the claim for me and represent me in any negotiations. I authorize the Agency to initiate a complaint to the Insurance Commissioner for any reason on my behalf. However if payment is denied I understand that I will be responsible for unpaid services, and agree to make payment within 15 days of final denial.

FREQUENCY /RIGHTS /HOTLINE /PROCEDURES

I understand that an RN will supervise all services. I understand the frequency of services. This frequency may change according to need.

  Frequency
                          

I certify that I have received an admission package: its contents have been verbally explained to me and copies left with me to refer to as needed. Admission package includes:

            

 

  • Patient Bill of Rights and Responsibilities
  • Complaint/Grievance Policy and Information About NYS DOH Hotline
  • Emergency Numbers and Emergency After Hours Information
  • Assignments Of Benefits/Financial Responsibilities
  • Advance Directives Including Out of Hospital DNR
  • HIPAA and Notice of Privacy Practices
  • Safety Tips to Prevent Falls
  • Hazardous Waste Disposal
  • Abuse and Neglect
  • Palliative Care
  • Infection and infectious disease prevention
  • Service provision during Emergencies, natural /manmade disasters including services during a pandemic
  • What I Need to Know About EVV Fact Sheet

 

            

I have signed I have not signed     a   Living Will/Advanced Directive  out Hospital DNR

I am  I am not             providing a copy for my record.

Medical Power of Attorney: Phone #:

I understand that this is my right and responsibility to be involved in my care and that I will be informed as to the nature and purpose of any technical procedure.

            
Patient                         

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