SERVICE Registration Form

Transcription

1 133 New Bridge Road #04-09 Chinatown Point Singapore Tel: Fax: SERVICE Registration Form SENIOR S PERSONAL PARTICULARS Name: (Chinese Characters) NRIC: (Pink / Blue) Date of Birth: Nationality: Gender: Male Female Age: Weight: kg Race: Chinese Indian Malay Others Religion: Marital Status: Single Married Divorced Widowed Occupation: Highest Education: Dialect/Language spoken: English Mandarin Malay Tamil Hokkien Cantonese Teochew Hainanese Hakka Others: Address: Postal Code: Home No: Mobile No: Type of residence: 1 room 2 rooms 3 rooms 4 rooms 5 rooms / Executive HDB Condominium Landed Others: (pls specify) Lift landing on every floor? Yes Home status: Rent Owned No Have you ever applied for MOH-ILTC Means-test Subsidy: Yes No Not Sure SOCIAL INFORMATION Total number of family members staying in the same house (including applicant): Any Current Caregiver: Spouse Maid Children None Is Caregiver trained: Yes No Caregiver Status: Full-time (Healthy / Frail) Part-time (Working / General) FAMILY & CAREGIVER PARTICULARS Name Relationship to Senior Address (if different from Senior s) As at 8 Dec

2 EMERGENCY CONTACTS 1) Name of Person to be contacted: Relationship Address Postal Code Home No: Mobile No: Office No: 2) Name of Person to be contacted: Relationship Address Postal Code Home No: Mobile No: Office No: HEALTH AND MEDICAL CONDITIONS (compulsory to answer all) How is the Senior s Mobility? Independent Wheelchair Bedridden Level of Assistance? Min. Assistance (1 person transfer) Max. Assistance (2 persons transfer) No Assistance (Senior is able to transfer on his own Can the Senior stand? No Yes Can the Senior walk? No Yes Can the Senior talk? No Yes Attached Hospital Discharge Report / Doctor s Memo? No Yes Is Senior sleeping on hospital bed? No Yes Not sure Any Commode with wheels at home? No Yes Not sure Can the Commode fit into toilet? No Yes Not sure Does the Senior have any infectious disease? No Yes (Pls specify) Does the Senior have any signs of Dementia? No Yes (Pls tick Yes only if Dementia is medically endorsed by doctor) Other medical conditions or medical history: SERVICE REQUIREMENT (Please tick the types of services required) A) HOME HELP SERVICES Companionship, Conversation, Recreation Assist in Exercises 普通復健运动 Activities 沟通交谈与陪伴 Meals Preparation 预备膳食 Personal Hygiene Care 个人护理 Errand Service & Grocery Shopping 用品购物 Medical Escort 医疗陪诊 Others 其它 Preferred Service Period: Service Timing: Frequency: Preference for icare Officer (subject to availability): Local Foreign No preference Preference for Home Help Service Days: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Preference Time-slot: 8am to 11 am 1pm to 3pm 4pm to 6pm As at 8 Dec

3 B) HOME NURSING SERVICES Change of Wound Dressing Last changed: Wound Care & Education Nasogastric Tube Change Last changed: Nasogastric Tube Care & Education Urinary Catheter Change Last changed: Urinary Catheter Care & Education Intermittent Catheterization Frequency: Stoma Bag Change Last Changed: Colostomy Care & Education Diabetes Mellitus Diabetes Type 1 Diabetes Type 2 Blood Glucose Monitoring Frequency: Glucose Range: Insulin Injection Frequency: Type of Insulin Used: Pre-load of Insulin Injections Frequency: Type of Insulin Used: DM Counseling Suctioning of Nasal Pharyngeal Frequency: Tracheostomy Tube Care & Education Tracheostomy Tube Dressing & Velcro Strap Change Comments Comments Other Nursing Services: To take Instructions from: Relationship: Contact No: Preferred Service Period: Service Timing: Frequency: As at 8 Dec

4 C) HOME MEDICAL SERVICES To take Instructions from: Relationship: Contact No: Preferred Service Period: Service Timing: Frequency: D) HOME PHYSIOTHERAPY / OCCUPATIONAL THERAPY SERVICES To take Instructions from: Relationship: Contact No: Preferred Service Period: Service Timing: Frequency: E) INTERIM CAREGIVERS PROGRAMME To take Instructions from: Relationship: Contact No: Preferred Service Start Date: Service Period: weeks PAYMENT MODE Cash Cheque Internet Bank Transfer Others (Pls specify) Payment Options: 1) ATM / Internet Bank Transfer - Our Bank Account DBS Bank code: 7171 DBS Branch code: 001 DBS Current Account no: For 1st time Internet Bank Transfer, please enter Elderly Name for payment reference. Please inform us once payment is made via Internet / ATM. 2) Cheque Payment please pay to : NTUC Health Co-operative Ltd Please write the Elderly Name, Invoice No. and Contact No. on the back of the cheque. Person who is making the payment: Address for Invoice & Receipt (if different from Senior s address): OTHER SPECIAL INSTRUCTIONS ON CARE-GIVING (If any) Union Member Offers - Any NTUC Union Members in the Family? Name of Union Member: NRIC: Relationship to the Senior: As at 8 Dec

5 INDEMNITY & DECLARATION 1. I, NRIC No of (Address) hereby declare that I will not hold NTUC Health Co-operative Ltd responsible or liable for any mishap or accident which may occur to *me/my when *I/he/she is receiving the services at our home. 2. I certify that the information given in the application is, to the best of my knowledge, true and complete. CONSENT FOR PROVIDING PERSONAL DATA 3. For the purposes of compliance with the Personal Data Protection Act (PDPA), I have obtained consent from the respective persons to provide his/her personal data in this Registration Form, to NTUC Health for the collection, use and disclosure of the Personal Data for the purposes of contacting the persons in case of emergency and in case any further information about the Senior relating to medical history and health is needed. (The Purpose ) 4. I agree and undertake to: (a) Notify NTUC Health if any of them withdraw their consent to the use and disclosure of the Personal Data for the Purpose; (b) Assist NTUC Health promptly with all access requests and complaints which may be received from individuals regarding the use of their Personal Data by the Company; (c) Indemnify NTUC Health and keep NTUC Health harmless against any legal action, claims, losses, damages, liabilities, penalties whatsoever which NTUC Health may incur or suffer as a result of the wrongful collection and use by the myself of the Personal Data and/or any breach by the myself of the Act and/or any my representations, warranties and/or undertakings contained herein. 5. I have read and accept the Terms & Conditions for Care@home services at Annex. I would like to receive marketing messages from NTUC Health via the following (please tick): Voice call Text Message All Name & Signature / Date FOR OFFICIAL USE Source: AIC Walk-in Others CARE COORDINATOR Full Rate YES / NO NMTS % Barthel Date Hrs / week TEAM LEADER Matching Received Date Matching Confirmed Date Service Start Date Service Day/s: Service Timing: ICO Assigned As at 8 Dec

6 Annex Terms & Conditions CHANGES, CANCELLATIONS AND TERMINATIONS CHANGES & CANCELLATIONS 1. Please inform us of any change/cancellation of service at least 3 working days before the appointment time. Otherwise, we will charge $5 per appointment change. For cancellation/termination of service, a $35 or 100% of the service fees whichever lower is applicable. Please call: (Mon- Fri; 9am to 6pm) Or care-home@ntuchealth.sg 2. All service terminations for regular, continuous long-term services must give at least TWO WEEKS (14 working days) notice. Except for ICS service, termination notice must be given at least 3 working days. 3. Service charges will be imposed for notice given less than TWO WEEKS (14 working days) or less than 3 working days for ICS service. 4. NTUC Health reserves the right to terminate the service immediately if and when the following situation arises: Senior s medical/physical/health condition becomes unsuitable for service Senior becomes mentally unstable or unsuitable for service Senior s home environment presents safety risks to our staff (e.g. presence of bed bugs) Senior or family member gets aggressive, violent, overly suspicious, abusive or has improper behavior towards any of our care staff 5. If, due to unforeseen circumstances, our icare officers need to change or cancel services (e.g. icare officer is on medical leave etc.), NTUC Health will try our best to replace the icare officer or change the service time, subject to manpower availability. 6. Payments can be made via: PAYMENT & CHARGES Cheque - payable to NTUC Health Co-operative Ltd & mail to 9 Bishan Place #10-02 Junction 8 Office Tower Singapore (Please write the Elderly Name, Invoice No. and Contact No. on the back of the cheque) ATM / Internet Bank Transfer - our Bank Account : DBS Bank code: 7171 DBS Branch code: 001 DBS Current Account no: For 1st time Internet Bank Transfer, please enter Elderly Name for payment reference. Please us the transfer acknowledgement receipt (without your bank balance) after payment is made. care-home@ntuchealth.sg GIRO Please contact or us for Giro Application Form. 7. Payment will be collected upon confirmation of service timing. 8. Service invoice will be sent to the client at the end of the service in the following month. 9. NTUC Health reserves the rights to withdraw the services if the payment is not received. PACKAGE POLICY 10. Service package is non refundable & non transferable and must be utilized within the calendar month. 11. Service package is only applicable for weekday service, Mon-Fri, 8am to 6pm. 12. A minimum of 3 hours of service per visit is required for utilization of Service Package. 13. Each service package is subjected to only 2 changes/cancellation of service timing in a month. As at 8 Dec

7 GENERAL Physical/Health Conditions 14. Seniors & Family members should co-operate with the icare Officer when he/she delivers the service and be involved in exercises & recreational activities provided. 15. Seniors & Family members who require any special assistance/arrangement or have any special information should share with NTUC Health at the point of registration. 16. Seniors & Family members are required to inform our staff on any infectious diseases if any. Failing which, we reserve the right to terminate services immediately. 17. Seniors & Family members should also keep NTUC Health and the icare Officer informed of any latest developments or information (improvement/deterioration) of Senior s state of physical and/or mental condition, as well as other relevant information (e.g. change of address/contact), in a timely manner. This is to ensure that the icare Officer is kept up to date and can take all the necessary monitoring and precautionary measures. This will also help us to provide better service to the senior. Medications/Medical Appointments 18. Family members must provide the icare Officer with all daily medications needed by the senior in a properly packed manner, with all necessary instructions. According to Government Regulations icare Officers are only allowed to remind and monitor the senior to take his/her medication. They are not allowed to administer medication. 19. Arranging medical appointments for the senior shall remain the responsibility of the family. However, medical escort services can be arranged with Care@home in advance. Charges remain as per normal hourly rates. Any transportation charges incurred shall be borne by the client. Valuables 20. The client is responsible to keep any important documents, valuable items & personal property, including but not limited to jewelry, money etc, in a safe and secured place. NTUC Health cannot be held responsible for unsecured items that are lost. 21. Family members should advise seniors not to keep any valuables on his/her body and to give any presents or money to the icare Officer. 22. Clients are STRONGLY discouraged from giving any monetary rewards or gifts to our care staff. Family Support 23. Family members should be an active partner in caring and supporting his/her senior by: - Keeping a 2-way communication channel (feedback/information sharing) with NTUC Health; Providing encouragement and assistance whenever the senior requires; Providing assistance to the senior in the care process if the senior physical size is beyond icare Officer s physical capability. Government Subsidy Schemes 24. The Client is liable to pay for the adjustment on the service rate whenever there is a revision to the subsidy level as determined by household means testing. 25. The Client s medical condition will be assessed upon registration to determine the number of service hours that would qualify for subsidy in using our services. Once enrolled with us, the client will be re-assessed every six months to determine the number of subsidized hours that the Client continues to be eligible for. As at 8 Dec

8 Personal Data Protection Act 26. Privacy a. You may wish to provide us with some or all of your Personal Data requested in this Form. b. By signing this Consent Form, you hereby grant NTUC Health and its officers, employees and agents the right to collect your Personal Data and to make use of all of your personal data, which is held by NTUC Health or will be collected in the future, for the purposes of offering you - healthcare and elderly care services; to conduct market research and analysis; for direct marketing through voice calls, text messages, , direct mail, facsimile messages and other forms of in-app advertisements all in connection with healthcare and elderly care services; to ascertain if you are eligible for discounts, privileges or benefits promoted by NTUC Health and/or other third parties which NTUC Health is associated all in connection with the provision of NTUC Health services including Care@home services. For further details and information please review our Privacy Policy which can be found at c. In addition, you also grant NTUC Health your consent, from time to time, to disclose some or all of your personal data held now or in the future by NTUC Health to NTUC Health s employees, related corporations, agents, volunteers, event organizers, independent contractors and other third parties that NTUC Health is associated with, but only in connection with the purposes mentioned in the paragraph above. We assure you that we are taking all measures necessary for the protection of your Personal Data. 27. Contacting You To the extent that any of the means of communication which you have provided us (which may include, your telephone number and fax number) is listed or will be listed in the future on the Do Not Call Registry ( DNC ), by ticking the relevant box(es) on page 5 above, you hereby grant NTUC Health your clear and unambiguous consent to contact you using all of the means of communication you have provided to NTUC Health including the means of voice calls, SMS, Whatsapp and MMS messages for the above-mentioned purposes. You confirm and agree that the consent you have given in this document do not replace any other consents which you already provided to any member of NTUC Health, and is in addition to any rights NTUC Health has by law, in connection with the collection, use and distribution of your personal data. 28. Withdrawal Of Consent You can withdraw some or all of your above consents at any time. For further information please refer to NTUC Health Privacy Policy as stated above. You hereby also confirm your agreement with all of the above and that you have read and agreed with all terms and conditions of NTUC Health Privacy Policy. * NTUC Health shall mean NTUC Health Co-operative Limited, their subsidiaries, related corporations, affiliates and agents. ** Personal Data shall mean data, whether true or not, about an individual who can be identified from that data; or from that data and other information which an organisation has or is likely to have access. Such Personal Data shall also refer to that which is already in the possession of NTUC Health or that which shall be collected by NTUC Health in the future. REGISTRATION Please submit the following documents to Care@home : 1. Recent Medical Report e.g. Discharge Summary from hospital (if any) or Doctor Memo 2. Medications prescription memos from the doctor 3. Copy of Applicant's NRIC 4. Completed Care@home Registration Form 5. Completed Application Form for ILTC Means-Test (if applicable) You may , Mail or Fax to: NTUC Health Care@Home 133 New Bridge Road #04-09 Chinatown Point Singapore Fax: care-home@ntuchealth.sg As at 8 Dec