CONSENT TO RECEIVE SERVICES: I hereby, authorize Serenity Care Services (Agency)to render appropriate home care services to me. I have been fully informed of the agency’s assessment and evaluation of my home care needs, the risk of receiving the care, and of declining the home care services. I accept the proposed Plan of Care and authorize services to be provided by the agency’s personnel. I believe my services to be: _____________________________________________________
CHARGE FOR SERVICES: Your initial services from the agency will include the following services, initial frequency of visits and charge per visit, if private insurance or private pay. Payor for services: ____________________________________________________________________________________
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CLIENT LIABILITY FOR PAYMENT: You have the right to be advised, before care is initiated, of the extent to which payment for services may be expected and the extent to which payment may be required from you, the Client. We are advising you, orally and in writing, about the cost of items and services to be provided.
MEDICAID/MA PLANS/PRIVATE INSURANCE/LONG TERM CARE:
The insurance company is ___________________________. This insurance company covers ______% of the charges. You are responsible for $__________._____ per visit, which is the balance after insurance pays. The deductible amount of $_________.____ will be billed to you. You will be responsible for charges related to the services provided to you by this agency and for the supplies used in providing care to you. You will be notified before these charges are implemented. This assignment shall not extinguish or diminish the Client’s obligation to pay the full fee to the company for services rendered. The Client shall receive credit for all sums collected pursuant to the agreement.
PAYMENT: You will receive a monthly bill for charges incurred. Payment is due weekly, after care is rendered. Our agency accepts payment in the form of a credit card, debit card or direct withdrawal from a bank account. If, at any time, the balance on the account exceeds $2,000 or 21 days, service will be discontinued until payment is received. It will assess interest of 1.5% per month on all balances over 30 days which you are responsible to pay.
HOLIDAY CHARGES: The 24-hour period constituting the following holidays will be billed at 1½ times the regular rate. The following are holidays which the agency celebrates: New Year’s day, Easter, Memorial day, Fourth of July, Labor day, Thanksgiving, Christmas eve, Christmas day and New Years’ eve.
CLIENT NAME (Last, First, MI): ____________________________________ MR # __________
CHANGE/CANCELLATION: I understand that the agency and I have the mutual ability to change or cancel the hours scheduled for service. (See next bullet for more details)
HOURLY CLIENTS: I will notify the agency 24 hours in advance should I desire to change or cancel the hours scheduled for service. I understand that a 2-hour minimum service fee will be charged if the caregiver arrives because I failed to contact the agency’s office. I understand that I must call the agency office for any schedule changes. This information cannot be relayed through the caregiver.
LIABILITY: The client is responsible for all agency collection costs, including attorney and court fees. I understand that no 3rd party payer, insurance, Medicare, or Medicaid will be billed or liable for services provided by the agency.
CONFIDENTIALITY: It is our policy to protect all clinical records against loss, defacement, tampering, and use by unauthorized person(s). The Client’s written consent is required for the release of medical information to persons not otherwise authorized by law (federal and state) to receive this information.
EMERGENCY MEDICAL TREATMENT: Agency staff will seek medical treatment for the client in the event of an emergency which may endanger client's life or cause disfigurement, if delayed. If there is a valid, signed DNR in the home at the time of the emergency, the DNR will be honored.
AUTHORIZATION for personal funds and vehicle:
I do OR do NOT authorize the agency to access to my personal funds in order to pay for services it provides to me. _______Client Initials
I do OR do NOT authorize the agency to use my personal vehicle in order to provide services to me. ______ Client Initials
ADVANCED DIRECTIVE: I certify that I have read and received a copy of the Client Rights and Advance Directives information specific for the state and that I am the Client, or am acting in the Client's behalf, and accept their terms.
I have prepared an advance directive regarding my healthcare and will provide a copy to the agency.
I have not prepared an advance directive and do not wish to at this time regarding my health care.
I have not prepared an advance directive but wish to make an advance directive at this time.
PERMISSION TO PHOTOGRAPH: Photography may be needed to assist in the clients’ care. Permission is hereby granted to allow photography for the purpose of care only.
I do OR I do Not allow photography
ACKNOWLEDGEMENT OF INFORMATION: I have received a copy of the Client Handbook which explains to me the services provided. I have also received verbal and written information in the handbook on the following:
Advanced Directives. I have received information regarding advanced directives and the agency’s policy on respecting my rights under the Patient Self Determination Act of 1990 and state law. In addition, I understand that the organization’s policy is to respect individual choice and to avoid discrimination based on whether or not you have an advance directive or a Do Not Resuscitate (DNR) directive.
Patients’ Rights and Responsibilities. I have been informed of my rights and of the agency’s complaint process which included the state’s toll-free hotline phone number.
Notice of Privacy Rights
Basic Home Safety.
Emergency planning for disaster planning and information related to a disruption in service in the event of a disaster.
Infection control & hand-washing techniques and disposal of biomedical waste
Discharge & Transfer Policy
Service Outline
Emergency contact information
Non-discrimination policies
Abuse, Neglect, and Exploitation: which includes the abuse and home health hotline numbers
Medication information, if appliable
CLIENT NAME (Last, First, MI): ___________________________________ MR # __________
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, in the event of an emergency during which the agency cannot meet my needs, the agency can transfer me to another agency that can provide the care I require.
I UNDERSTAND that drug testing is at the agency’s discretion which complies with state requirements.
I UNDERSTAND that If I choose to hire a current agency employee (or former employee who has rendered services for me in the past 12 months) The agency will charge a fee of 30% of full time (2080) hours at the employee's bill rate. After 12 months, the fee is 15%. After 18 months, 12% and after 24 months, 10%.
I UNDERSTAND that the agency is the employer of the home care worker and is responsible for all state and federal regulations regarding employment. The agency conducts a criminal background check on all employees, including fingerprinting, and reference checks. The agency is responsible for payment of wages, withholding of payroll taxes, payment of unemployment insurance, worker’s compensation, and time off. Th supervisor is responsible for supervision of the employee, assignment of duties, and oversight of care provided. All disciplinary action is handled by the agency.
I UNDERSTAND that the agency reserves the right to substitute employees at its discretion and to make supervisory visits on staff as needed. Every effort will be made to provide a caregiver; however, the agency cannot guarantee scheduling. The agency strives for continuity of care but suggests that a family member or friend be designated as a backup caregiver for those rare instances when the agency may be unable to provide caregivers.
I UNDERSTAND The agency makes an effort to provide uninterrupted services; however, sometimes interruptions are unavoidable due to inclement weather or natural disasters. During the interruption of essential services, I agree to provide or arrange for backup care. If I cannot provide care, I understand that the agency may assist in arranging for transfer to an appropriate emergency facility.
I AGREE: I agree to carry standard homeowner's insurance policy or similar tenant's policy on the client residence. I understand that the agency limits its liability for property loss or damage to claims filed within 30 days of occurrence and will file any claims within the period. I agree to hold the agency harmless from liability for any damage of any nature caused by the use of any automobile while performing services for client. I hereby release the agency, from any and all claims, and causes of action involving any and all damages to my property except those damages caused solely by the negligence of agency staff.
I agree to provide information regarding the physical, emotional, and psycho-social information on an ongoing basis to ensure optimal care and have participated in the development of the plan of care. I understand the reasons for the services and agree with the plan of care. I recognize that I have the right to refuse treatment or terminate services at any time by notifying the agency’s office. Also, the agency may terminate service by notifying me of termination and reason without penalty.