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CLIENT SERVICE AGREEMENT (Cont’d) (Spanish Translation in the back) Patient: _________________________________ Medical Record: _________________ Page 2 SECTION TWO HOME HEALTH SERVICES TO BE FURNISHED, FREQUENCY AND CHARGES : SKILLED NURSING________________________________ HOME HEALTH AIDE__________________________________ PHYSICAL THERAPY ______________________________ MEDICAL SOCIAL WORKER ___________________________ SPEECH THERAPY ________________________________ OCCUPATIONAL THERAPY___________________________ OTHER:_____________________________________________________________________________________________ ALSO I AUTHORIZE THE AGENCY'S RN/RPT TO PERFORM VISIT OF SUPERVISION , EVERY _______________ DAYS. STATEMENT OF PATIENT RIGHTS, RESPONSIBILITY AND ABUSE REGISTRY : I CERTIFY THAT I HAVE READ, UNDERSTOOD AND RECEIVED A COPY OF THE STATEMENT OF PATIENT RIGHTS AND RESPONSIBILITY WHICH HAS BEEN EXPLAINED TO ME VERBALLY BY A REPRESENTATIVE OF THE AGENCY I UNDERSTAND THE POLICY AND HAVE RECEIVED A COPY WITH THE TOLL FREE ABUSE PHONE NUMBER (1-800-962-2873), AND HHA HOTLINE (1-888-419-3456). ADVANCE DIRECTIVE AND LIVING WILLS: I HAVE RECEIVED WRITTEN INFORMATION REGARDING MY RIGHTS TO MAKE DECISIONS CONCERNING MEDICAL CARE, INCLUDING THE RIGHT TO ACCEPT OR REFUSE MEDICAL OR SURGICAL TREATMENT AND THE RIGHT TO FORMULATE ADVANCE DIRECTIVES UNDER STATE LAW. I HAVE AN ADVANCE DIRECTIVE: 9 YES 9 NO. I HAVE A LIVING WILL: 9 YES 9 NO. IF YES, LOCATION OF LIVING WILL:______________________________________ I HAVE A PATIENT ADVOCATE/PROXY: 9 YES 9 NO: MY PATIENT ADVOCATE/PROXY IS: Name: _______________________________ADDRESS:___________________________________PHONE:__________________ I WANT TO USE THE DNR ORDER 9 Y 9 N (If yes, complete the official Legal Form) HIPAA/OASIS: NOTICE OF PRIVACY PRACTICES: I HAVE RECEIVED A COPY OF THE AGENCY'S NOTICE OF PRIVACY PRACTICES, I HAVE DISCUSSED AND RECEIVED A COPY OF THE CLIENT INFORMATION/ORIENTATION HANDBOOK. CONSENT FOR HOME VISIT: I HEREBY CONSENT TO HAVE STATE/FEDERAL/ACCREDITATION HEALTH SURVEY PERSONNEL TO CONDUCT A " HOME VISIT" TO ENSURE THAT THE FEDERAL/ACCREDITATION REQUIREMENTS ARE MET AND TO ASSIST IN EVALUATING THE EFFECTIVENESS QUALITY OF HOME HEALTH SERVICES THAT I RECEIVE FROM THE AGENCY I UNDERSTAND THAT CONSENT FOR THIS VISIT IS VOLUNTARY AND NONE OF MY RIGHTS TO CONFIDENTIALITY OR PRIVACY ARE WAIVED BY MY CONSENT. I HAVE BEEN TOLD AND UNDERSTAND THAT REFUSAL TO A HOME HEALTH VISIT WILL HAVE NO EFFECT ON THE LEVEL OR NATURE OF MEDICARE/MEDICAID BENEFITS TO WHICH I AM ENTITLED. PATIENT RELEASE TO PHOTOGRAPH: I HEREBY GRANT THE AGENCY, AND THEIR REPRESENTATIVES, PERMISSION TO TAKE PHOTOGRAPHS OF ME AND TO USE THE FINISHED PHOTOGRAPHS IN ANY LEGITIMATE WAYS THEY DEEM PROPER. FURTHER I RELINQUISH AND GIVE TO THE AGENCY, ALL RIGHTS, TITLE AND INTEREST I MAY HAVE IN THE FINISHED PICTURES, NEGATIVES, REPRODUCTIONS AND COPIES OF THE ORIGINAL PRINTS AND NEGATIVES. I ALSO GRANT THE RIGHT TO GIVE TRANSFER AND EXHIBIT THE NEGATIVES, ORIGINAL PRINTS, OR COPIES AND FACSIMILES, MAIL, DELIVERY, THEREOF TO ANY RESPONSIBLE INDIVIDUAL, BUSINESS FIRM, OR PUBLICATION, OR TO ANY OTHER ASSIGNEES. PATIENT SERVICE AGREEMENT : I HAVE RECEIVED A COPY OF THE AGENCY'S PATIENT SERVICE AGREEMENT AND HAVE ALL QUESTIONS AND CONCERNS ANSWERED TO MY SATISFACTION. ALSO I AUTHORIZE TO ____________________________, (RELATION TO PATIENT ________________) TO SIGN ALL DOCUMENTS , BECAUSE I'M UNABLE TO DO SO. REASON UNABLE TO SIGN: _________________________________________________________________________________________________________. ONE PATIENT SIGNATURE : ADMISSION CONSENT/AGREEMENT FORM IS USED IN ALL PATIENT ORIENTATION BOOKLETS (this booklet), AND IS USED TO ACKNOWLEDGE RECEIPT, UNDERSTANDING AND APPROVAL OF THE CONTENTS OF THE PATIENT ORIENTATION BOOKLET AND FORMS ( BILL OF RIGHTS , GRIEVANCE PROCEDURES, TRANSFER AND DISCHARGE POLICY , EMERGENCY PLAN) – ALL IN ONE BOOKLET AND WITH ONLY ONE PATIENT SIGNATURE. THE CONFUSION AND PATIENT’S EFFORTS OF SIGNING MULTIPLE FORMS IS ELIMINATED. 2 _____________________________________________________ ______________________ SIGNATURE OF CLIENT OR AUTHORIZED REPRESENTATIVE DATE _____________________________________________________ RELATIONSHIP OF AUTHORIZED REPRESENTATIVE _____________________________________________________ ______________________ SIGNATURE OF AGENCY’S REPRESENTATIVE DATE www.pnsystem.com 305.818.5940 (Specialized in clinical forms) sample