Healthcare Home Health Application

Healthcare Home Health Application

This application requests information necessary to determine eligibility for home health services and to establish a plan of care. Completion of this form does not guarantee admission. Please answer all questions fully and sign the certification at the end.

Patient Information

Emergency Contact

Primary Care and Referring Provider

Insurance and Billing

Medical History

Please indicate known medical conditions. Check all that apply and provide details where requested.

Functional Status & Home Environment

Please indicate current functional abilities and safety concerns.

Services Requested

Indicate requested or referred home health services. A plan of care will be established by a licensed clinician.

Authorizations, Consents, and Financial Responsibility

By signing this application, the applicant or authorized representative certifies that the information provided is true and complete to the best of their knowledge and authorizes the release and exchange of health information necessary for treatment, payment, and health care operations. The applicant authorizes the home health agency to obtain medical records, coordinate care with other providers, and bill third-party payors on the applicant's behalf. The applicant understands they are financially responsible for charges not covered by insurance or other payors.

I authorize the release of medical information to the above-named home health agency and to insurers, physicians, and other providers as necessary to process claims and coordinate care. This authorization includes records related to mental health, substance use, and HIV/AIDS where applicable unless otherwise indicated below.

This authorization will expire on:

HIPAA Acknowledgment

I acknowledge receipt of the agency's Notice of Privacy Practices and understand my rights regarding use and disclosure of my protected health information. I understand I may revoke this acknowledgment in writing except to the extent the agency has already acted in reliance on it.

Advance Directives / Special Instructions

Please indicate whether advance directives are in place and provide copies if available.

Certification

I certify that the information provided on this application is accurate and complete. I understand that falsification or omission of material information may result in denial of services or termination of services. I agree to notify the agency of any changes in health status, insurance coverage, or contact information.

Acknowledgment of Rights

The applicant has the right to accept or refuse services; the right to be informed of the plan of care; the right to participate in care planning and discharge planning; and the right to be free from abuse, neglect, and exploitation. The applicant may withdraw consent for services at any time in writing.

Signature

The undersigned attests that they are the patient or are authorized to act on behalf of the patient and consent to home health services as described above.

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