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CLIENT SERVICE AGREEMENT (Spanish Translation in the back) Patient: _________________________________ Medical Record: _________________ Page 1 VOLUNTARY ADMISSION: I VOLUNTARILY CONSENT TO ADMISSION TO THE AGENCY, AND TO TREATMENT THAT MAY BE ADVISED AND OR RECOMMENDED BY MY PHYSICIAN AND TREATMENT TEAM. I REQUEST A COPY OF THE PLAN OF TREATMENT: Y_______ N_______ CONSENT TO RECEIVE SERVICES: I HEREBY AUTHORIZE THE AGENCY, TO RENDER APPROPRIATE SERVICES AS PRESCRIBED BY MY PHYSICIAN, OR BY ANY OTHER PHYSICIAN WHO MAY BE TREATING ME, INCLUDING ALL DIAGNOSTIC AND THERAPEUTIC TREATMENT THAT MAY BE CONSIDERED ADVISABLE OR NECESSARY IN THE JUDGMENT OF THE PHYSICIAN. I HEREBY AUTHORIZE THE AGENCY, OR YOUR AGENTS TO PERFORM ANY WORK IN TAKING BLOOD SAMPLES FROM ME OR ADMINISTERING INJECTIONS OR INTRAVENOUS THERAPY FOR NORMAL MEDICAL PRACTICE. I HEREBY AUTHORIZE THIS WORK UNDER PHYSICIAN'S ORDERS, WHILE A PATIENT WITH YOUR ORGANIZATION. I CERTIFY THAT I AM NOT RECEIVING HOME HEALTH CARE SERVICES FROM ANOTHER AGENCY. I AM ALSO AWARE THAT ONLY ONE HOME HEALTH AGENCY WILL BE PAID ONCE I AM ADMITTED TO THIS AGENCY. I HEREBY ACKNOWLEDGE THAT I AM NOT UNDER ANY CIRCUMSTANCE ABLE TO OPERATE ANY MOTOR VEHICLE. EMERGENCY MEDICAL SERVICES: I UNDERSTAND THAT DURING THE COURSE OF MY TREATMENT THE NEED FOR EMERGENCY TREATMENT AND/OR TREATMENT AND/OR TRANSFER TO A HOSPITAL MAY BECOME NECESSARY AND APPROPRIATE. I UNDERSTAND THAT THE AGENCY DOES NOT PROVIDE EMERGENCY MEDICAL CARE AND THEREFORE SHOULD THE NEED FOR SUCH TREATMENT AND/OR TRANSFER MAY BE DEEMED NECESSARY AND APPROPRIATE, THE AGENCY STAFF WILL CALL 911. I CONSENT TO SUCH EMERGENCY TREATMENT AND/OR TRANSFER TO A HOSPITAL AND HEREBY INDEMNIFY THE AGENCY FROM SUCH EMERGENCY TREATMENT AND/OR TRANSFER. I AGREE TO ASSUME SOLE RESPONSIBILITY FOR ALL CHARGES INCURRED FOR SUCH TREATMENT. RELEASE OF INFORMATION: I AUTHORIZE ALL THE PHYSICIANS, HOSPITALS, NURSING HOMES, CLINICS, AND OTHER HEALTH CARE PROVIDERS RELEASE OF MEDICAL INFORMATION RELEVANT TO MY CARE TO THE AGENCY I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION FROM MY RECORDS TO ANY LICENSED INSTITUTIONS, STATE, FEDERAL, OR ACCREDITED INSTITUTIONS FOR THE PURPOSES OF PROVIDING CONTINUITY OF CARE, ESTABLISH CONTINUITY OF CARE, ESTABLISH CORRECT REIMBURSEMENT, ESTABLISH NEED FOR SERVICE OR AS AUTHORIZE BY LAW. I PLACE NO LIMITATIONS ON HISTORY OR ILLNESS OR DIAGNOSTIC/ THERAPEUTIC INFORMATION INCLUDING ANY TREATMENT FOR SUBSTANCE ABUSE, PSYCHIATRIC DISORDERS, OR ACQUIRED IMMUNODEFICIENCY SYNDROME. "RELEASE OF INFORMATION" WILL BE PERFORMED ACCORDING TO HIPAA REGULATIONS. SECTION ONE INSURANCE BENEFITS AND PAYMENT: I HEREBY AUTHORIZE MY PRIVATE INSURANCE CARRIER TO PAY INSURANCE BENEFITS TO THE AGENCY, AND AGREE TO THE RELEASE OF ALL MEDICAL INFORMATION TO MY INSURANCE CARRIER IF SHOULD BE REQUIRED BY ANY PROGRAM I HAVE BEEN ADMITTED THROUGH MEDICARE AND NO CHARGES WILL BE EXPECTED I hereby request and authorize payment directly to THE AGENCY I understand that to receive Medical covered home care services, I must meet the qualifying criteria as outlined under information of Medicare coverage criteria statement contained in the home folder. if your home care services conform to this rule, your Medicare home care services should generally be covered without liability for payment. If services should be determined as denied or non-covered by Medicare, then the patient will be notified via letter and payment will be at the discretion of the agency. I understand that I am financially responsible for charges not paid under any assignment, charges will not exceed the agency's regular Medicare charges ( SHU YLVLW ). I certify that the information given by me in the applying for payment under the title XVIII and/or XIX of the social security act is correct. I authorize the release of all records required to act on this request. I request that payment of authorized benefits be made on my behalf. furthermore, I hereby declare that I do not belong to any Health Maintenance Organization (HMO). If it is found otherwise, I will be responsible for the charges Incurred. I HAVE BEEN ADMITTED THROUGH MEDICAID AND MY RESPONSIBILITY IS $ 2.00 CO-PAY PER VISIT WITH A MAXIMUM OF ONE CO-PAYMENT PER DAY. I HAVE BEEN ADMITTED THROUGH __________________HMO, _______________________COMMERCIAL INSURANCE,__________________MEDICARE INSURANCE AS A SECONDARY PAYER. The charges will be determined through third party contracts. , +$9( %((1 $'0,77(' THROUGH 9(7(5$16 $'0,1,675$7,21 9$ I HAVE BEEN ADMITTED THROUGH PRIVATE PAY AND THE CHARGES ARE SPECIFIED IN THE PRIVATE PAY AGREEMENT ATTACHED 6(&7,21 ,, . I CERTIFY THAT THE FINANCIAL INFORMATION INDICATED ABOVE, RELATED TO THE PAYMENTS MADE BY INSURER OR THIRD PARTY PAYER, THE SCOPE AND INTENT OF COVERAGE, AND THE CHARGES FOR NON-COVERED SERVICE CHARGES, HAS BEEN EXPLAINED AND UNDERSTOOD. XXX QOTZTUFN DPN 4QFDJBMJ[FE JO DMJOJDBM GPSNT sample