Healthcare Home Page Application

HEALTHCARE HOME PAGE APPLICATION

This application authorizes enrollment for home-based health services provided by the agency named on the administrative page. Completion of this form constitutes a request for services and constitutes informed consent and authorization for the release of medical information as described below. Please complete all sections in full and sign the certification at the end of this application.

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance and Billing

Requested Home Health Services

Requested Start Date:

Skilled Nursing   Physical Therapy   Occupational Therapy   Speech Therapy

Home Health Aide   Medical Social Work   Other:

Days: Mon Tue Wed Thu Fri Weekend

Medical History

Ambulatory without assistive device Uses walker Wheelchair user Bedbound

Consent for Home Health Services

I authorize the home health agency and its licensed clinicians to provide medically necessary services in my home as ordered by my attending practitioner. I acknowledge that home-based services may include physical contact, movement, medication management, and interventions that carry risks including but not limited to falls, allergic reaction to medications, worsening of symptoms, and infection. I understand that the agency will take reasonable precautions to mitigate these risks.

I have the right to refuse any treatment or service and to withdraw consent at any time by notifying the agency in writing or by telephone. Withdrawal of consent may affect the agency's ability to continue providing services, and may result in discharge from the program in accordance with agency policy.

Authorization to Release Medical Information

I authorize my healthcare providers and payers to disclose medical records and other protected health information to the home health agency for the purposes of treatment, payment, and healthcare operations. I further authorize the agency to release information to third-party payers and other providers as necessary for coordination of care and billing.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the agency's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures and that the agency will consider such requests in accordance with applicable law.

I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility and Assignment

I agree to provide accurate insurance information and to be responsible for payment of charges not covered by my insurer, including co-payments, deductibles, and services denied by the insurer. I authorize payment of benefits directly to the provider and assign to the provider any insurance or third-party benefits payable for services rendered.

I authorize assignment of insurance benefits to the home health agency.

Additional Information / Special Needs

Certification and Attestation

By signing below I certify that the information provided on this application is complete and accurate to the best of my knowledge. I understand that willful falsification or omission of information may result in denial, delay, or termination of services. I agree to inform the agency promptly of any changes in my health status, insurance coverage, or contact information.

I certify that the information on this application is true and complete.

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