Street Address:  City: State: Zip Code:

Home Telephone Number:  Cell Phone Number:

Emergency Contact Name:  Emergency Contact Telephone Number:

Physician Name:

SERVICES TO BE PROVIDED:

Community Home Health Care (“Community”) can provide the following services. The current rate for each service is attached hereto. The duration and frequency of the services will be in accordance with your current medical order:

Frequency

Personal Care Aide (“PCA”)

Home Health Aide (“HHA”)

Nursing

Therapy - Occupational

Therapy - Physical

Therapy - Speech Language Pathology

Home and Community Support Services (“HCSS”)

Other

In addition to the above, clinical supervision will be conducted: a) at the start of care; b) when there is a change in personnel providing care if the aide does not have documented training and experience in performing the tasks prescribed in the plan of care; and c) at least the following intervals unless otherwise required by your payor contract:

THE EXTENT TO WHICH PAYMENT FOR AGENCY SERVICES MAY BE EXPECTED FROM ANY THIRD PARTY PAYORS AND THE EXTENT TO WHICH PAYMENT MAY BE REQUIRED FROM YOU:

Private Pay Patient – Community will bill you directly and you will be expected and required to pay the following for the above services:

x Per Hour

x Per Day

x Per Visit

x Per Visit

 $ x Per dayPer hourPer visit

You expressly agree:
a) To pay an initial deposit of (“Two Week Deposit”); b) that all on-going weekly bills for services provided by Community will be automatically charged to your credit card pursuant to the credit card authorization form attached hereto; and c) Community may elect to satisfy unpaid bills with the Two Week Deposit funds. Should you have an increase in services hours or services, you will be required to adjust the amount of the Two Week Deposit to cover a full two weeks of service hours. You will be billed for one and one half times the normal billing rate on the following holidays: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day.

Public or Private Third Party Health Insurance – You have coverage through traditional Medicaid, a Medicaid managed care plan, or a commercial health insurance plan. These carriers will be primarily responsible, and directly billed, for services provided by Community. As such,there is no payment to Community expected directly from you and you will be responsible only for applicable cost-sharing amounts charged by your carrier (e.g., authorized co-payments, deductibles, etc.).

Notwithstanding the foregoing, you expressly agree as follows:

• To pay the applicable private pay rate(s) reflected on the attached statement: a) during any elimination period(s) established by your carrier; b) in the event of non-payment of any and all charges not covered by your carrier, to the extent allowable under Medicaid or insurance plan rules; and c) should you lose your coverage eligibility;
• All payments, to the extent required, for services provided by Community should be made payable to Community Home Health Care and sent to 73-A Troy Road, East Greenbush, NY 12061. If this is not possible, you expressly agree that payments are to be made payable to both you and Community and you grant Community an irrevocable right to endorse such payments over exclusively to Community;
• If you receive payment directly from your insurance plan you will immediately forward it to Community; and
• Community has not warranted, represented, or guaranteed that your carrier will authorize or pay for any services provided to you
• I must 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 Community Health Care has submitted on my behalf, I hereby elect not to appeal the denial myself, but I do hereby authorize Community Health Care 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.
• 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.

Community will advise you of any changes in information provided herein (e.g., rates and/or the extent to which payment may be expected from you and others) as soon as possible, but no later than thirty (30) calendar days from the date the agency becomes aware of the change. Additionally, if after services begin, a change occurs to your status that necessitates the provision of new/additional services, we will notify you regarding the extent of payment and liability prior to the initiation of those new/additional services. A new Agreement for Service will not be required. If you accept services after receiving notice of a rate change, the new rate shall be applicable. You may discontinue receipt of services at any time.

CLIENT RIGHTS AND RESPONSIBILITIES:

You have a number of important rights as a Community patient. These rights are described for you in a separate document contained in your admission packet. You are encouraged to familiarize yourself with these rights and avail yourself of them, as necessary. You also have a number of responsibilities as a Community patient. These include, but are not limited, to the following:

• Notifying the office of any changes to your scheduled hours as soon as possible. Cancellations must be communicated at least twenty-four (24) hours in advance and if such notice is not provided, or you otherwise refuse the services of a scheduled worker, you will be billed for four (4) hours of service as permitted by applicable law;
• Providing cleaning supplies and equipment needed by caregivers;
• Securing personal items and valuables;
• Securing any dogs or cats in the residence throughout the duration of any shift, by crating or containment in a separate room, if requested;
• Maintaining a smoke-free environment throughout the duration of any shift, if requested;
• Allowing Community to assign caregivers in a non-discriminatory manner; and
• Treating caregivers with respect.
• I have been notified of my right to voice a complaint and understand that I may first file a complaint with the Administrator or Director of Patient Services at 518-449-1142. I understand that this is not an emergency line. I will Call 911 in an emergency.
• I am aware that instructions for filing a complaint are included in the Client Rights provided at onboarding. I can also contact the New York New York State Department of Health, Office of Health Systems Management, Phone 1-800-628-5972, Contact by Mail: Department of Health Metropolitan Regional Office, Complaint Intake Program Address: 90 Church street, New York, New York 10007
• I have been informed what to do in an emergency /natural disaster. I have been informed verbally and in writing regarding Agency policy on abuse, neglect and exploitation, agency drug testing policy and hazardous waste disposal in the home.
• HIPAA - I have received a Notice of Privacy Practices and consent to the agency’s use and/or disclosure of protected health information for payment, treatment and Agency’s Health care operations.

Community may discontinue services to you if you: a) do not meet the above patient responsibilities; b) for non-payment of applicable fees; or c) if you become ineligible for third party coverage and do not agree to continue as a private pay patient. In such event, you agree to make appropriate alternate arrangements for your continued care.

I have been informed that Community Home 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 Home Health Care and authorize the agency to release medical information to my physician, the facility of my choice, payer source or accrediting/regulatory/consulting organizations, as appropriate. I authorize the release of the Plan of Care and Discharge Summary upon my transfer to another health care facility. 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.

• I have received a copy and explanation of my Patients’ Rights & Patients’ Responsibilities and Conduct, as appropriate.
• I acknowledge receipt of information pertaining to Palliative Care, Advance Directives, Do Not Resuscitate Order, Living Will and Health Care Proxy. I understand my rights and responsibilities as they have been explained.

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 #:

Private Pay

Guarantor Name:  Guarantor Relationship:

Guarantor Address:  Guarantor Phone Number:

Guarantor: Guarantor acknowledges and agrees that due to his/her relationship to the patient, he/she receives benefits from the provision of services by the Agency to the patient. I acknowledge the client’s payment responsibility for the services provided by the Agency. In the event that the patient fails to make the required payments hereunder, I will be directly responsible for such payments and I personally guaranty payment of the amounts due to the Agency for the services provided to Patient. The Agency is permitted seek payment from me without having to exhaust its remedies against the patient.

Community is committed to informing all clients of Agency policies and procedures at the start of care. Clients are encouraged to ask questions and participate in this interaction. Community has provided me with an Admission package which includes but is not limited to the following:

Agency Mission Statement

What I Need to Know About EVV Fact Sheet

Available Services and Rates

Geographic Service Area

Hours of Operation

Patient Bill of Rights and Responsibilities

Emergency Numbers and Agency Emergency after Hours Information

Assignments of Benefits

Financial Responsibilities

Consent & Charges

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

Admissions Criteria

On-Call Guidelines

Plan for Care

Medical Records

Discharge, Transfer & Referral

Cell phone use

Ethics

Drug Free Workplace

Patient Satisfaction

Problem-Solving & Complaint Procedure

Home & Fire Safety

Preventing Hospitalizations

Infection Control at Home

Disaster Planning & Emergency Preparedness

Advance Directives

Living Will

Medical Power of Attorney for Health Care

Non-Hospital Order Not to Resuscitate

Notice of Privacy Rights and Practice

These documents have been verbally explained to me and copies have been left with me to refer to as needed. My signature below indicates that I acknowledge that the above mentioned was reviewed with me by the Registered Nurse or Agency designee at the start of care. I was given an opportunity to ask questions and I fully understand this information.

The undersigned acknowledges that he/she has read the foregoing (which was also explained orally) and accepts the terms set forth herein.