Policy Manual sample

MDT Home Health Care Agency, Inc. The following form will be used if any Patient decide to transfer to our Facility: Patient Name: _____________________________ MR# ___________________ Beneficiary- Elected Transfer Use: The HIQH (ONLINE INQUIRY SYSTEM) has indicated that the beneficiary is under an active episode of care with another H.H.A. The transfer has been elected by the patient or patient representative. Complete the following: 1. The original online inquiry system was accessed on (date) _____________ it was discovered that the patient has an active episode under care with the following agency: _____________________________________________ 2. The patient's physician (name) ________________________________ was contacted on (date) _____________ and approved this transfer. 3. The patient or patient care giver was notified that the initial H.H.A will no longer receive Medicare payment on (date of transfer) _________________ and agreed to the transfer. Name of person contacted: ____________________________________________ Relationship: _______________________________________________________ 4. The initial H.H.A was contacted on (date of transfer) _______________ and notified of the transfer to our agency. _____________________________ _____________________ Signature of Agency Representative Date Home Health Agency Policies A-191