Healthcare LTC Document

HEALTHCARE LONG-TERM CARE (LTC) ADMISSION, CONSENT & AUTHORIZATION

Facility and Admission

Facility Name:    Admission Date:

Patient Information

Date of Birth:    Gender:

Insurance & Coverage

Medical History

Advance Directives & Representative

I have a Living Will or Advance Directive.    I have designated a Durable Power of Attorney for health care.

Consent for Long-Term Care Services

Scope of Services: The facility will provide interdisciplinary long-term care services including, but not limited to, nursing services, medication management, assistance with activities of daily living, rehabilitation therapies as ordered by the attending practitioner, and routine monitoring of medical and psychosocial status. The specific care plan will be developed and updated by the interdisciplinary team.

Risks and Benefits: I acknowledge that the provision of long-term care and related medical treatment involves potential risks, including but not limited to adverse medication reactions, infection, falls, and changes in chronic condition status. The anticipated benefits include stabilization or improvement of health status, symptom management, and support with daily living. I understand that no guarantee of outcome is made.

Voluntary Consent: By signing below I authorize the facility and its agents to provide the care described above. I understand that I may withdraw this consent at any time by providing written notice to facility administration, except to the extent that the facility has already acted in reliance on this consent.

Authorization to Release Medical Information

I authorize the facility to release protected health information to persons or entities for purposes of treatment, payment, and health care operations, or as otherwise required or permitted by law, as described below.

Expiration: This authorization expires on , unless earlier revoked in writing. I understand that once information is disclosed to the recipient it may no longer be protected by federal privacy regulations.

Financial Responsibility & Assignment

The undersigned accepts financial responsibility for charges not covered by insurance, including co-payments, deductibles, and services deemed non-covered. The undersigned authorizes assignment of benefits and payment directly to the facility for services rendered. The facility may bill third-party payers and pursue collection for unpaid balances in accordance with facility policy.

Medicare/Medicaid Authorization: I authorize release of information necessary to determine eligibility and to process claims for benefits under Medicare, Medicaid, or other government programs, when applicable.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the facility's Notice of Privacy Practices, which describes how my health information may be used and disclosed and my rights with respect to such information under applicable law.

I acknowledge receipt of the Notice of Privacy Practices.

Revocation and Withdrawal of Authorization

This authorization may be revoked at any time by submitting a written revocation to the facility's administrator, except where the facility has already relied upon the authorization. Revocation will not affect disclosures previously made in reliance on this authorization while it was in effect.

Patient Certifications

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand the nature and scope of the services to be provided, the financial responsibilities, and my rights regarding privacy and the revocation of authorizations. I further certify that I am the patient or the legally authorized representative with authority to execute this document.

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