* = Required Information
AUTHORIZATION AND AGREEMENTS FOR HOME HEALTH SERVICES

CONSENT FOR SERVICES – The undersigned release CAREFORCE HOMEHEALTH INC. (CHI) from all liabilities incurred as a result of medical treatments provided by staff of the Agency. The undersigned requests admission to CHI and consents to such care and treatment in my residence as ordered by my physician. I understand that if I am in such condition as to need hospitalization or special services not provided by CHI, such service may be arranged by me or my legal representative or my physician and CHI should in no way be responsible for failure to provide the same and is hereby released from any liability arising from the fact that I am not provided with such additional care. The undersigned consents to being photographed for purposes of documenting a wound or medical problem and their progress. I consent to testing my blood for blood borne diseases such as HIV/AIDS and Hepatitis in the event an employee is accidentally exposed to my blood or bodily fluids.

NOTICE OF NON-DISCRIMINATION – Careforce Homehealth, Inc. does not discriminate against any person on the basis of race, color, national origin, disability or age in admission, treatment or participation in its programs, services activities or employment.

USE AND DISCLOSE HEALTH INFORMATION – The undersigned authorized CHI to use and/or disclose health information for treatment, payment, or health care operations. The undersigned have the right to refuse to sign consent, however if unsigned, CHI have the right to refuse treatment. You have the right to revoke this consent at any time. Your revocation of this consent must be in writing and directed to the Administrator at 847-388-0060.

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS – The undersigned hereby consents to the release of information by any hospital, health care provider or physician from whom I received services to CHI and authorizes CHI to disclose all or part of medical records to hospitals, physicians, health care provider, regulatory, accrediting or state agencies or community service agencies, as necessary for my care or review of my care, to any insurance carrier(s) or other payer(s) to process my claims.

NOTICE OF PRIVACY PRACTICES – I have received the Notice of Provider Privacy Practices and all my questions and concerns about the privacy of my health information have been addressed adequately.

ADVANCE DIRECTIVES:

I have a written Advance Directive in the following forms:
      Living Will
      POA
      DNR
      Other
      Location


I have not executed an advance directive of any kind and do not intent to execute such directive at this time.

I am ready to execute an advance directive and will notify Careforce Homehealth, Inc. after I do so

I agree to provide the agency copies of my Advance Life Directive

I refuse to provide the agency copies of my Advance Life Directive

I understand that the staff of CHI and its associate will not be able to follow the terms of my advance directives not until I will provide them with a copy of these documents. I have been informed of CHI policies and procedures.

AUTHORIZATION FOR PAYMENT: I certify that the information given to me in applying for payment is correct. I authorize Careforce Homehealth, Inc. to contact Medicare, Medicaid or Private Insurance on my behalf to verify eligibility and benefits. I request that payment of the authorized benefit and release if all records required to act on this request be made on my behalf. I also authorize Careforce Homehealth, Inc. to appeal on my behalf in case of any adverse determination by the intermediary or any insurance carrier about the coverage of the services given to me. I understand that Careforce Homehealth, Inc. customary charge is $135.00 - $180.00 per visit. I further confirm that effective today no other home health care agency shall bill or be paid by Medicare, Medicaid, or Private Insurance on my behalf except Careforce Homehealth, Inc.

ASSIGNMENT OF MEDICARE/MEDICAID – The undersigned certifies that the information given in applying for payment under Title XVIII and/or Title XIX of the Social Security Act is correct. I understand CHI accepts assignment for Medicare and Medicaid, and that my responsibility for these programs is limited to the deductible and co-pay for Medicare Part “B” (and Medicaid when required by law) and for services, which I have been advised that are not covered by Medicare Part “A” or Part “B.” The undersigned is aware that if I transfer to CHI, the previous agency will no longer provide services or receive Medicare payment after the date of the Medicare beneficiary’s elected transfer. I hereby direct that payment of authorized insurance/health plan reimbursement, be made on my behalf directly to CHI for any medical services, supplies and products provided to me while I am under CHI care. In the event that payments of insurance benefits are made directly to me, I will endorse to the order of CHI all checks for such payment.

MEDICARE + CHOICE, HMO or PPO ENROLLMENT – If at any time while I am receiving services from CHI I enroll into a Medicare + Choice, HMO, PPO or other managed care plan, or there is a change in my insurance/health plan carriers or benefits, I will notify CHI immediately. If I do not communicate this change to CHI, and costs occur which are not paid for by Medicare, Medicare + Choice, HMO, PPO, or other managed care plan, I will be responsible to pay the amount billed to me for the services I received from CHI after the change.

MEDICARE – MEDICAL SUPPLIES & OUTPATIENT THERAPY – I understand that selected medical supplies (not enteral) and outpatient therapy services are covered by Medicare under home health benefit and must be arranged for by CHI for coverage. Only supplies and outpatient therapy services arranged by CHI are covered, otherwise, I am liable for payment for those supplies and services because they will not be covered by Medicare.

NOTICE OF FINANCIAL LIABILITY I acknowledge that I have been informed of and received the Agency charge for services, any anticipated insurance liability and any anticipated liability I may have for the cost of services. I also acknowledge that I may contact the Agency at any time should I have any problem or question regarding the above

Skilled Nursing Physical Therapy Speech Therapy Occupational Therapy Medical Social Worker Home Health Aide

Skilled Nursing

Physical Therapy

Speech Therapy

Occupational Therapy

Medical Social Worker

Home Health Aide

ACKNOWLEDGEMENT OF INFORMATION – I acknowledge that I have received and understand the following information.

My questions and concerns have been addressed to my satisfaction,

Patient Rights and Responsibilities

Notice of Privacy Medical Information Practices

OASIS Privacy Notice

Advance Directive Information

Procedure for Patient Comments, Questions or Complaints

Emergency Preparedness Information

The Agency’s Transfer and Discharge Policies and Instructions

After Office Hours Nurse-on-Call Contact Numbers

Community Health Accreditation Partner (800) 656 9656

HMO Notice

Influenza Vaccination and Pneumonia Vaccination

My (Our) Financial Responsibility

Applicable Fees and Policies Concerning Payment for Services/Products

Grievance Procedure

Contact information of agency’s administration name: Raymond DeLeon, RN (847)388-0060, 7301 N. Lincoln Ave Suite 199 Lincolnwood, IL 60712

Illinois State Home Health Hotline: (800) 252 4343 – 24hours a day – 7 days a week

English Spanish Other
Yes No

Received Admission Packet
I also understand that CHI may terminate their services with proper notification and reason for termination. I understand how to communicate a concern verbally and in writing regarding treatment or care, agency services, including complaints regarding the implementation of advanced directives as well as the right to ask questions about local home health agencies to:
1. Careforce Homehealth, Inc. c/o Raymond DeLeon, RN at telephone number 847-388-0060, 24 hours/7 days a week;
2. Community Health Accreditation Partner (800) 656-9656; and Illinois Department of Health Services (800) 252-4343
I and/or representative/caregiver have participated to the degree capable in the development of this Plan of Care.

STATEMENT OF PATIENT RIGHTS AND RESPONSIBILITIES

Being a patient of Careforce Homehealth, Inc., you have a right to be informed about your rights and responsibilities before we provide care, treatment, or services and to exercise those rights. Patient-Selected representative or Legal Representative may exercise your rights when you have been judged incompetent.

Patients have the right to: Dignity and Respect 484.50(c)(3)
• Have their property and person treated with respect
• Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property

Patients have the right to file complaints with the home health agency: Complaints 484.50(c)(3)
• Regarding their treatment and/or care that is provided
• Regarding treatment and/or care that the agency fails to provide
• Regarding the lack of respect for property and/or person by anyone who is providing services on behalf of the home health agency. Communicate a concern verbally and in writing regarding treatment or care, agency services, including complaints regarding the implementation of advanced directives as well as the right to ask questions about local home health agencies to: Careforce Homehealth, Inc. - Raymond DeLeon, RN – Administrator (Tel. No. 847-388-0060)

Language Services and Auxiliary Aides 484.50(c)(12): Patients have the right to be informed of the right to access auxiliary aids and language services and how to access these services.

Privacy and Access to Medical Records 484.50(c)(6): Patients have the right to a confidential clinical record and patients gave the right to access and to the release of patient information and clinical records

Patients have the right to: Decision Making, Content, and Services Provided 484.50(c)(4)(ii-viii)and(5)
• Participate in, and be informed about, and consent or refuse care in advance of and during treatment with respect to: completion of all assessments; the care to be furnished, based on the comprehensive assessment; establishing and revising the plan of care; the disciplines that will furnish the care; the frequency of visits; expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; any factors that could impact treatment effectiveness; and any changes in the care to be furnished
• Receive all services outlined in the plan of care.

Free from Reprisal 484.50(c)(11): Patients have the right to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity

Patients will be advised of: Financial Information 484.50(c)(7)(i-iv):
• The extent to which payment for home health services may be expected from Medicare, Medicaid, or any other federallyfunded or federal aid program known to the HHA.
• The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the home health agency
• The charges the individual may have to pay before care is initiated;
• Any changes in the information regarding payment for service as soon as possible, in advance of the next home visit.

Patients have the right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. (484.50(c)(8)

Discharge/Transfer Policy: Patients have the right to be informed of and receive a copy of the agency’s policy for transfer and discharge.

Advocacy Resources 484.50(c)(9);(10)
Patients will be advised of:
• The telephone number and hours of operation of the state’s home health hotline. The purpose of the state hotline is to receive questions and complaints about Medicare certified and state-licensed home care agencies as well as lodge complains about the implementation of Advance Directives.
COMMUNITY HEALTH ACCREDITATION PARTNER (CHAP): (800) 656-9656
ILLINOIS STATE HOME HEALTH HOTLINE: (800) 252-4343; 24 hours a day/7days a week
• The names, addresses, and telephone numbers of the following Federally-funded and State-funded entities that serve the area where the patient resides:
     ○ Agency on Aging – Cheryl Barrett - 160 N LaSalle St 7th Flr, Chicago, IL 60601 (217) 785-4477
      Cook – Cheryl Barrett - 160 N LaSalle St 7th Flr, Chicago, IL 60601 (217) 785-4477
      Du Page – Natasha Belli – 421 N County Farm Rd, Wheaton IL 60187 (630) 407-6500
      McHenry – Jeri Colusy – 1910 S Highland Ave Ste 100, Lombard IL 60148 - (630) 293-5990
      Kane – Jeri Colusy – 1910 S Highland Ave Ste 100, Lombard IL 60148 (630) 293-5990
      Lake – Jeri Colusy – 1910 S Highland Ave Ste 100, Lombard IL 60148 (630) 293-5990
      Will – Jeri Colusy – 1910 S Highland Ave Ste 100, Lombard IL 60148 (630) 293-5990
     ○ Protection and Advocacy Agency – Amy Wiatr-Rodriguez – 233 N Michigan Ave Suite 790, Chicago IL 60601 (312) 938-9858
     ○ Aging and Disability Resource Center – Amy Wiatr-Rodriguez – 233 N Michigan Ave Suite 790, Chicago IL 60601 (312) 938-9858
     ○ Quality Improvement Organization – KEPRO 5201 W Kennedy Blvd Ste 900, Tampa FL 33609 (855) 408-8557
     ○ Center for Independent Living – IL Network of Center for Independent Living – 1 W Old State Capitol Plz Ste 501, Springfield IL 62701 (800) 587-1227

Patient Responsibilities

• Notify the provided or changes in their condition (e.g. hospitalization and symptoms to report);
• To ask questions about care or services;
• To notify the home health agency of if the visit schedule needs to be changed;
• To inform the home health agency of changes made to the advanced directives;

• To promptly advise the home health agency of any concerns with the services provided;
• To provide a safe environment for the agency staff;
• To carry out mutually agreed responsibilities; and
• To accept the consequences for the outcomes if the patient does not follow the plan of care.
• To follow the plan of care;

INFLUENZA/PNEUMONIA VACCINE CONSENT
Yes No

a. Recently had the Influenza Vaccine
b. Allergic to eggs
c. Severe reaction to flu-shot in the past

a. 65 years old and older
b. Having one or more medical conditions (50-64 years old)
c. Personal Preference

Influenza Vaccine Administered by SN
Patient referred to home visiting physician or to the primary care physician
Patient referred to the local health department or other community location (e.g. local pharmacy, flu-shot clinic, and hospital) where flu-shots are available
Arranged for the local health department or other private or community health organiation to provide the flu-shot in the patient home
Yes No
Yes No

a. Had been vaccinated with Penumonia in the past
b. Personal Preference

a. 65 years old and older
b. Has chronic health problems (heart disease, lung disease, sickle cell disease, diabetes)
c. Personal Preference

Penumonia Vaccine Adminisstered By SN
Patient referred to home visiting physician or to the primary care physician
Patient referred to the local health department or other community location (e.g. local pharmacy, flu-shot clinic, and hospital) where Penumonia Vaccines are available
Arranged for the local health department or other private or community health organization to provide the Penumonia Vaccine in the patient home
Yes No
Yes No
Yes No
AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INFORMATION

I hereby authorize that the protected health information regarding the above-named person be forwarded:

FROM

TO

Face Sheet
History & Physical
Laboratory Report
Operative Report
Discharge Summary
Nurses Notes
X-ray/Radiology Report
Emergency Report
Pathology Report
EKG/EMG/EEG Report
Consultation Report
Progress/Physician Notes
Other

I must check one or more of the following types of health information that I do not want released to the above named Recipient. I understand that if I do not check any of the three (3) boxes, the health information released to the named Recipient may include any of the following:
Diagnosis, Evaluation and/or treatment for alcohol and/or drug abuse
Records of HTLV-III or HIV testing (AIDS test) result, diagnosis and/or treatment
Psychiatric, psychological records or evaluation and/or treatment for mental, physical and/or emotional illness including narrative summary, tests, social work assessment, medication, psychiatric examination, progress notes, consultations, treatment plans, and/or evaluation.

I also understand that this Authorization is subject to revocation/withdrawal by me at any time in writing to the medical record contact person at this site of care except to the extent that action has already been taken to release this information. This Authorization shall remain valid unless revoked but will expire in 1 year after signing. I have a right to inspect a copy of the health information to be released and if I do not sign this Authorization, the institution named above will not release my health information. The above named person/institution will not refues to treat me based on whether I agree to allow my health information to be used and disclosed to others.

REDISCLOSURE: Notice is hereby given to the patient or legal representative signing this Authorization that Advocate Health Care cannot guarantee that the Recipient receiving the requested health information will not re-disclose or all of it to others. Notice is hereby given to the Recipient that law prohibits the re-disclosure of any health information regarding drug and/or alcohol abuse, HIV and mental health treatment.

BENEFICIARY ELECTED TRANSFER

I understand that my previous home health agency, Located at , will no longer provide home health services after today's date and no longer receive payment on my behalf.

I also understand that I am now electing to transfer to Careforce Homehealth, Inc. to provide me with home health services effective immediately.