Healthcare Agency Confirmation Letter

HEALTHCARE AGENCY CONFIRMATION LETTER

Agency Identification

This letter confirms that the Healthcare Agency named above has reviewed the referral and accepts responsibility to provide home health services to the individual identified below, subject to the conditions and terms contained in this confirmation.

Patient Information

Patient Name:

Date of Birth:    Gender:

Service Details

Anticipated Service Start Date:    Anticipated Service End Date:

Insurance and Billing

Insurance Provider:

Policy Number:    Group Number:

The Agency will bill the primary insurer for covered services. The patient or responsible party remains financially responsible for copayments, deductibles, non-covered services, and any amounts not paid by third-party payers.

Authorizations, Privacy and Release

By signing below, the patient or authorized representative authorizes the release of protected health information (PHI) to third parties and payers as necessary to coordinate care, obtain payment, and fulfill treatment objectives. This authorization includes, but is not limited to, communication with physicians, other health care providers, insurers, and designated family members involved in care coordination.

Authorization Expiration Date: . If no date is provided, this authorization will remain in effect for the duration of the current course of care unless revoked in writing.

The patient acknowledges receipt of the Agency's Notice of Privacy Practices and understands how PHI will be used and disclosed. The patient may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it.

I acknowledge receipt of the Notice of Privacy Practices and consent to the uses and disclosures described therein.

I authorize the Agency to obtain, release, and discuss medical information and records as necessary to coordinate care and process claims.

Terms of Services and Termination

The Agency agrees to provide services consistent with the professional standards of care applicable to the services described above. Services are provided subject to the medical necessity as determined by the patient's ordering practitioner and the Agency's clinical policies.

Either the patient or the Agency may terminate services with written notice. Termination by the Agency may occur immediately if continuation of services would constitute a risk to the health or safety of staff or others, or if the patient materially breaches responsibilities such as timely payment or cooperation with care plans.

Patient Responsibilities

The patient or responsible party is responsible for: maintaining a safe home environment for care delivery; providing accurate and complete medical and insurance information; being present for scheduled visits or notifying the Agency of cancellations within the required notice period; and paying any amounts not reimbursed by third-party payers.

Additional Instructions / Notes

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