Healthcare Home Health Agency Form

HEALTHCARE HOME HEALTH AGENCY FORM

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Relationship:    Contact Phone:

Insurance and Billing Information

Policy Number:    Group Number:

Referral and Services

Anticipated Start of Care:    Number of Visits per Week (estimated):

Skilled Nursing    Physical Therapy    Occupational Therapy    Speech Therapy

Home Health Aide    Medical Social Work    Infusion Therapy    Wound Care / Dressing Changes

Telehealth Visits    Other:

Medical History & Current Status

Has patient had a recent fall? Yes    No    Ambulatory status:

Home Safety & Equipment Needs

Oxygen    Walker    Wheelchair    Hospital Bed

Consent for Services, Treatment and Billing

I authorize Home Health Agency to provide home health services as ordered by my physician. I understand services may include skilled nursing, therapy, aide services, medical social work, and other services described above. I consent to skilled nursing interventions, assessments, and treatments deemed necessary by licensed clinicians.

I authorize the agency to submit claims to my insurer and to accept assignment of benefits. I understand I am financially responsible for charges not covered by insurance, including co-payments, deductibles, non-covered services, and services denied due to lack of medical necessity documentation.

I have the right to refuse or withdraw consent at any time by contacting the agency. Withdrawal of consent may affect the agency's ability to continue providing services. I understand reasonable notice may be required to discontinue services safely.

By checking this box I consent to the provision of home health services and to the billing practices described above.

HIPAA Authorization & Release of Information

I acknowledge receipt of the agency's Notice of Privacy Practices. I authorize the agency to use and disclose my protected health information for treatment, payment, and health care operations as necessary for the provision of services.

I authorize the release of medical information to my insurer, referring physician, caregivers, and other providers involved in my care. This authorization includes clinical records, medication lists, and visit notes required for continuity of care and billing.

This authorization will expire on: . I may revoke this authorization in writing at any time, except to the extent disclosures have already been made in reliance on this authorization.

By checking this box I acknowledge I have received and understand the Notice of Privacy Practices and authorize release of information as stated.

Financial Responsibility & Patient Rights

The patient or responsible party is responsible for payment of services not paid by insurance. Billing disputes will be addressed according to agency policy; however, payment for covered services remains the responsibility of the patient until resolved.

The patient has the right to be treated with respect, to receive care in a safe environment, to participate in care planning, to voice grievances without retaliation, and to be informed of changes in services or charges.

By checking this box I accept financial responsibility as described above.

Additional Authorizations

Acknowledgment and Signature

By signing below I certify that the information provided is accurate to the best of my knowledge. I authorize the Home Health Agency to provide the services described, to release and obtain necessary medical information, and to bill my insurance for services rendered. I understand my rights and responsibilities as described in this form.

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