Healthcare Support Service Package

HEALTHCARE SUPPORT SERVICE PACKAGE

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Service Package Details

Proposed Start Date:    Proposed End Date:

Select all services included in this package:

Personal care (bathing, grooming)    Medication management

Wound care    Mobility assistance / transfers

Therapy coordination    Transportation to appointments

Social / caregiver support    Nutrition counseling

Remote monitoring    Other:

Fees, Billing, and Insurance Authorization

Standard fee for selected package: $ per .

I authorize the provider to bill my insurance for covered services. I understand I remain responsible for any co-payments, deductibles, and services denied by insurance.

Consent for Services and Acknowledgments

By signing this Healthcare Support Service Package, the patient or patient representative consents to the provision of the services described above. The patient acknowledges that:

1. Services will be provided in accordance with applicable professional standards and the provider's policies.
2. The patient retains the right to withdraw consent or discontinue services at any time by providing written notice. Withdrawal of consent will not affect obligations for fees incurred prior to termination.
3. Caregivers will document services provided and any adverse events; the patient will be informed of clinically significant changes.

I consent to the services and understand the risks, benefits, and alternatives of the proposed support services.

Confidentiality and HIPAA Acknowledgment

The provider will protect the privacy of the patient's health information in accordance with applicable privacy laws. Protected health information will be used and disclosed only for treatment, payment, and health care operations, or as otherwise authorized by the patient in writing.

I acknowledge receipt of the provider's privacy practices and authorize the release of necessary information to insurers and involved providers for billing and care coordination.

Emergency Procedures & Advanced Directives

In the event of life-threatening emergency, the provider will initiate emergency medical services. The provider will follow the patient's advance directive if one is on file and applicable to the situation.

Advance directive on file: Yes No    If yes, location of document:

Limitations, Termination, and Amendment

The provider will not perform services beyond the scope of training or license. The provider reserves the right to modify the scope of services when clinically necessary with notice to the patient. Either party may terminate services with written notice. Termination will be effective in accordance with the provider's policies unless immediate termination is required for safety or regulatory reasons.

Authorization and Expiration

This authorization to provide and bill for the described services is effective as of the Service Start Date and will expire on: unless earlier revoked in writing by the patient or authorized representative.

By signing below the patient or authorized representative certifies that the information provided herein is accurate to the best of their knowledge, that they have had the opportunity to ask questions and receive answers about the services, fees, and privacy practices, and that they authorize the services described in this package.

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