Healthcare CNY Hospice Form

Healthcare CNY Hospice Form

Patient Information

Patient Name:

Date of Birth: Gender: Male Female Other

Primary Phone: Alternate Phone:

Relationship: Phone:

Insurance Information

Policy Number: Group Number:

Subscriber Name (if different):

Medical History & Current Status

Advance Directives & Medical Decision Makers

I have an advance directive / living will on file. Document location:

I have designated a medical power of attorney. Name:

Do Not Resuscitate (DNR) order in effect

Consent for Hospice Care

I authorize Healthcare CNY Hospice and its authorized staff to provide hospice and palliative services as described to me or the patient named above. Services may include medical assessment, nursing, counseling, social work, spiritual care, medication management for comfort, and coordination with other providers. I understand the primary goal of hospice is palliation and comfort, not curative treatment, and care will be focused on symptom control and quality of life.

Risks and benefits: I acknowledge that hospice interventions carry potential risks and benefits. Benefits may include improved symptom relief, psychosocial support, and care coordination. Risks may include side effects of medications and limitations on curative treatments. I have had the opportunity to ask questions and have received answers satisfactory to me.

Right to refuse or withdraw: I understand I may refuse any proposed treatment or withdraw consent to hospice services at any time. Withdrawal of consent will be documented and instructions provided for continuation or transfer of care. Withdrawing hospice services does not affect the right to receive other medical care.

Release of Information & Coordination of Care

I authorize Healthcare CNY Hospice to obtain and release medical and billing information necessary for treatment, payment, care coordination and quality assurance. This includes sharing clinical information with hospital, primary care, specialists, pharmacies, home health agencies and insurers involved in my care. I understand that information disclosed may include diagnoses, medication lists, and summary of care.

This authorization remains in effect until: . I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on it.

Financial Responsibility

I understand that hospice will bill my insurance and/or third-party payers for services provided. I accept responsibility for any copayments, deductibles, or charges not covered by insurance. I agree to provide accurate insurance information and to cooperate with hospice staff regarding authorization and billing.

Privacy and HIPAA Acknowledgment

I acknowledge that I have been offered a copy of Healthcare CNY Hospice's Notice of Privacy Practices that describes how medical information about me may be used and disclosed and how I can access this information. I understand my rights under applicable privacy laws and that reasonable efforts will be made to protect the confidentiality of my health information.

I acknowledge receipt of the hospice Notice of Privacy Practices.

Medical and Safety Considerations

I agree to notify hospice staff of significant changes in condition, new medications, or new treating providers. I understand hospice staff will instruct on safe medication administration and home safety. I authorize hospice staff to provide emergency measures for comfort as clinically indicated until other emergency services are engaged.

Patient Statement & Certification

I certify that the information I have provided on this form is accurate to the best of my knowledge. By signing below I consent to hospice services as described, authorize release of information as indicated, and accept financial responsibility as described. I understand that I may revoke this consent in writing at any time, except where actions have already been taken.

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