Welcome To Brightside Adult Day Service

Size: px
Start display at page:

Download "Welcome To Brightside Adult Day Service"

Transcription

1 Did you know? Some Brightside Facts: We have served Rockford & surrounding area since We maintain a client/staff ratio of 6 to 1. We focus on the Person-Centered Care approach. We have a nurse on duty! We serve breakfast, hot lunch & snack each day, meeting nutritional requirements for seniors. We have a daily exercise program. We have a Respite Program for people who only need our service occasionally. We are a part of Lifescape Community Services, Inc., which includes Meals on Wheels, Information and Assistance, Transportation, Caregiver Assistance, Grandparents Raising Grandchildren and Senior Dining Sites in Winnebago, Boone, Ogle and Lee counties Our Brightside Mission: To provide activities, programs & services which assist older adults & their caregivers in maintaining independent, meaningful & purposeful lives. Welcome To Brightside Adult Day Service This booklet contains important information for you & your family concerning the Brightside program. Please hang on to this info for your reference! BRIGHTSIDE (LONGWOOD) 1055 E. State Street, Rockford IL (815) Hours of Operation: 7:30AM 5:30PM, M-F LongwoodADS@lifescapeservices.org (815) Lifescape-Brightside Adult Day Services does not discriminate on the basis of age, race, color, sex, national origin, handicap or disability, religion, ancestry, marital status and status upon discharge of the military service. It is also in compliance with the Illinois Human Rights Act; The U.S. Civil Rights Act; Section 504 of the Rehabilitation Act; The Age Discrimination Act; The U.S. and Illinois Constitutions; American with Disabilities Act and all other applicable laws. Rev 8/2013

2 Frequently Called Numbers Brightside (General info, report absence, intake & referral information, transportation questions, Longwood site questions, etc.) Lifescape Community Services (General information on services for seniors, including Meals on Wheels, Information and Assistant, Caregiver Assistance, Transportation, Grandparents Raising Grandchildren, Senior Dining Sites, Senior Expo, Senior Follies, referral sources, etc.) Free Visit Day Want to learn more about Brightside Adult Day Service? Schedule a free visit day! We invite you to spend a day with us enjoy the activities, meet clients and staff, eat lunch, learn more about what Adult Day Service can do for you! Call to schedule your free visit. Para-transit Visiting Nurses Association As always, you are invited to stop in and take a look at our site. Give us a call! Thanks. Alzheimer s Association (Rockford)

3 18 Exceeding CCP Contract Hours of Service To our clients who receive Community Care Program Assistance: Those utilizing the Community Care Program (CCP) are required by CCP to sign a Client Agreement. This agreement indicates the daily maximum amount of adult day service hours CCP will provide. Clients who exceed CCP contract hours may be charged for the costs of service. If this situation applies to you or if you would like to request an increase in hours, you should contact your case manager through the Visiting Nurses Association ( ). Requesting re-determination may result in an increase in daily maximum hours allowed. We do everything possible to ensure you do not exceed the approved CCP hours. If CCP hours are exceeded, it will be necessary for Brightside to pass this cost on to the client. The amount of hours exceeding the daily maximum will be totaled and billed at the current rate for private pay clients. Please understand that only when the daily maximum of hours is exceeded will this charge be applied. To Report a Change in Attendance Brightside does not bill clients for days they are absent; however, we ask that you notify our office of an absence in advance whenever possible. Please report a change in scheduled days by calling If you cannot alert us of an absence in advance (for instance, due to illness), please call as soon as you are aware of the change. We really appreciate it if you call before 7:30 A.M. Please leave a message on our answering machine. Respite Services If you need an additional day or request respite care, please alert us as we certainly can provide this service. Brightside Holidays In observance of holidays, Brightside is closed on the following days : New Years Day Memorial Day 4 th of July Labor Day Thanksgiving Day Thanksgiving Friday Christmas Eve (observed date changes yearly) Christmas Day (observed date changes yearly) 3

4 What is Adult Day Service? Adult day services are community based group programs designed to meet the needs of functionally and/or cognitively impaired adults through an individual plan of care. These structured, comprehensive programs provide a variety of health, social and other related support services in a protective setting during any part of a day, but less than 24 hour care. How do people pay for Adult Day Services? Various reimbursement sources are available to clients and their families. For those participants under the age of 60 years of age, the Department of Rehabilitation is an option. The Community Care Program is often an excellent resource for those over age 60. Veterans are able to receive financial assistance through the local or regional VA office. Should one not qualify for the above-mentioned assistance, a reasonably priced private pay fee schedule has been developed. The average cost of a day at ADS is a bargain by far in comparison to the cost of services from a home health nurse and/or the cost of a skilled nursing facility. Mandated Reporters Please note that all staff at Brightside are Mandated Reporters in the State of Illinois. If you have questions about Elder Abuse, please contact the Illinois Department on Aging at Advanced Directives Brightside staff have been taught to provide First Aid and CPR when needed; they are trained to call the paramedics when it medical crises occur on site. Some people do not want medical treatment in emergencies. Advanced directives are legal documents that alert us to your wishes you put in writing the kind of healthcare you want to receive should you become unable to make treatment decisions. In Illinois, Living Wills & Power of Attorney for Healthcare are two kinds of advanced directives. Do-Not-Resuscitate (DNR) Some people do not want to receive CPR. A DNR order means that you request cardiopulmonary resuscitation (CPR) not be started if your heart stops beating. To ensure your wishes are met, an original, written, signed and dated Do-not-resuscitate order (DNR) must be in your chart, on our site. Please note: if we don t have a written, complete DNR order on site, we follow our policy (do emergency first aid/cpr & call paramedics). Federal law requires you be alerted of your right to make decisions about the health care you get now and in the future. Brightside has available, on request, information concerning the Illinois law on Advanced Directives, Powers of Attorney for Health Care, Living Wills, Do Not Resuscitate Orders and a Statement in the Absence of Advance Directives. For more info, talk to your medical professional. The State of Illinois, Department of Human Services & the Illinois Department of Public Aid have excellent information on their websites regarding advanced directives & Do Not Resuscitate orders. Forms/IL pdf

5 Transportation (continued) Dogs: Dogs must be securely chained or fenced at pick-up/drop-off times. Drivers will not leave the bus if threatening dogs are loose at or near the participant s home. The driver will wait 5 minutes for the animal to leave the vicinity or be confined. If the situation has not changed in that time, the driver will leave. If a client is not going to be attending Brightside as scheduled, PLEASE call us and let us know! We don t want the bus waiting for someone or making an extra trip. The sooner you call the better. Please leave a message if no one answers. To report a change in schedule, call And finally, Safe Pick-up and return: If ADS is unable to pick up a client due to an unsafe situation at the home, Brightside staff will notify the responsible party; transport by ADS will not be provided that day. If ADS is unable to return a client to his/her home due to an unsafe situation (such as no one is home as scheduled, no key, etc.), the driver will return client to Longwood. The office will notify the responsible party to pick up the client before our 5:30 PM closing. 16 What s with all the paperwork? In the Beginning When a client starts attending Brightside, there are all sorts of forms that need to be completed! We realize there is a lot of paperwork to complete--please know that it really is required and is extremely important! The forms must be completed & returned to our office before the client s first day of attendance. If you need help completing the forms or have questions about the information requested, please do not hesitate to call us. All information is kept confidential. YEARLY PAPERWORK During the year, we may ask you to complete additional forms such as updating medical information, additional authorizations, etc. We promise not to ask for anything we don t need! If you have questions about anything we ask for you to fill out, please call! Paperwork we will require includes but is not limited to: Plan of Care (every six months) Medical Information & Physician info update Emergency Contact Information update; Consumer Satisfaction Survey HIPAA agreement Household Income Statement (if receiving subsidized care) 5

6 Brightside: Philosophy of Care It is our philosophy that in providing adult day service to our clients we approach each person as a unique individual, a person with strengths and weaknesses, a person with potential for growth and development and that each individual has much to offer to the program in terms of wisdom & experience. It is our philosophy that the holistic approach be applied in the provision of care to the clients. In applying the holistic approach, the interrelationship among the physical, social, emotional and environmental aspects of well-being is recognized and valued. It is our philosophy that we promote positive attitudes toward self-image, restoring, maintaining and stimulating capacities for independence while providing supports for functional limitations. It is our philosophy that the environment is that of a homelike setting, one that is pleasant, enjoyable and comfortable, one that is easily compared to a living room rather than an institution. It is our philosophy that the atmosphere is warm and caring; that respect, enthusiasm and enjoyment are evident to all who enter the site; that the understanding and stimulation of the mind and body encourages well-being and is demonstrated in the staffs every action. Brightside: Statement of Client Rights Brightside ADS respects the rights of the clients and caregivers involved in ADS programming. ADS Staff ensures client rights are maintained and respected as listed: The right to be treated as an adult, with consideration, respect, and dignity, including privacy in treatment and in care for personal needs; The right to participate in a program of services and activities designed to encourage independence, learning, growth, and awareness of constructive ways to develop one s interests and talents; The right to self-determination within the day service setting, 6 Transportation (continued) All Aboard! On arrival, driver sounds the horn briefly or calls from the bus using a cell phone, and waits no longer than 5 minutes for response. Drivers are unable to wait longer than this due to the scheduled route. If the participant has not exited the home in 5 minutes, the driver has been instructed to leave. Safety First. Caregivers are to keep the path to the bus clear of obstacles, ice and snow. A clear path to the bus is for everyone s safety. If an issue is reported to me and the situation/ issue is not adequately addressed by client/caregiver, transportation to/from Brightside may be suspended or terminated. Once the situation/issue is addressed, ADS will resume. For comfort, safety and cleanliness: eating, drinking, chewing tobacco and smoking are not allowed on the ADS bus. Prior to departure, the driver ensures the client is seated securely and wearing a seatbelt. If client is in a wheelchair, the driver secures the wheelchair using approved restraints. Three Wheeled Scooters: The use of three wheeled scooters is not allowed on site. We just don t have the room to have scooters at Brightside! We can provide a wheelchair for use during transportation and at the site. 15

7 Transportation Private Transportation: In the interests of safety, the family member/ caregiver transporting participants to Brightside ADS is required to accompany clients in to the activity room. We ask the same at the end of the day. Brightside Transportation: Our routes are expanding every day! We try to accommodate requests but there are areas we cannot yet provide service. Rockford Para transit provides transport for much of our area. If you have been approved for Brightside ADS Bus transportation, you must fill out & return the TRANSPORTATION REQUEST FORM before transport can begin. For those who ride the Brightside ADS Bus: ADS Transportation is Curb to Curb service. Drivers stay with the bus. Family members/caregivers are expected to walk participants to/from the bus. Drivers are not allowed to walk/escort clients until they are at the bus! We appreciate your understanding in regards to curb-to-curb service. 14 including the opportunity to: -participate in developing or changing one s plan for services; -decide whether or not to participate in any given activity; -be involved to the extent possible in program planning and operation; -refuse treatment and be informed of the consequences of such refusal; -end participation in the adult day center at any time; The right to a thorough initial assessment, development of an individualized plan of care, and a determination of the required level of care; The right to be cared for in an atmosphere of sincere interest and concern in which needed support and services are provided; The right to a safe, secure, and clean environment; The right to receive nourishment and assistance with meals as necessary to maximize functional abilities and quality of life; The right to confidentiality and the guarantee that no personal or medical information will be released to persons not authorized under law to receive it without the participants written consent; The right to voice grievances about care or treatment without discrimination or reprisal; The right to be fully informed as documented by the participant s written acknowledgement of all participant s rights and responsibilities and of all rules and regulations regarding participant conduct and responsibilities; The right to be free from harm, including unnecessary physical or chemical restraint, isolation, excessive medication, abuse, or neglect; The right to be full informed, at the time of acceptance into the program, of services and activities available and related charges; The right to communicate with others and be understood by them to the extent of the participant s capability. 7

8 Brightside: Statement of Client Responsibilities Brightside ADS clients have responsibilities as active members of the ADS program. To the extent possible, the responsibilities are to be carried out by the client or by the caregiver on behalf of the participant, if necessary. Brightside ADS staff ensures clients understand their responsibilities as participants of the ADS program. Client Responsibilities include: The responsibility to treat personnel with respect and courtesy. The responsibility to communicate with staff to develop a relationship of trust. The responsibility to make appropriate choices and seek appropriate care. The responsibility to ask questions and confirm understanding of instructions. Plan of Care An individualized Plan of Care is developed for each Brightside client, utilizing information from doctors, case managers, the participant and his/ her family, and from staff observation. We encourage family members and caregivers to take an active role in the care planning process. 8 Alzheimer Association s Safe Return Program Safe Return is a nationwide ID, support & registration program. It provides assistance if a person becomes lost locally or far from home. Assistance is available 24/7, whenever a person is lost or found. There is a registration fee. If you would like more information on this program, please contact us at If you are already participate in this program, let us know! Confidentiality We take confidentiality seriously! Visitors to the site must sign a Confidentiality Agreement when visiting. We require a signed, dated Authorization of Disclosure before talking with others. An Authorization is good for one year or until revoked. Please help us with confidentiality by completing Authorizations in a timely manner; keep the Emergency Contact list up to date; and, understand why we don t release information!! Brightside ADS staff maintains confidentiality of all participants as defined by Administrative Codes, including but not limited to Section ; (a-1, 2; f- 4o;) (d-1i and 2H); and, Health Insurance Portability and Accountability Act (HIPAA) of CFR Authority Sec of SSA (42 USC 1320-d- 1329d-8), 262 of Pub. L , 110 Stat 202`-2031 and sec 264 of Pub. L (42 USC 1320d-2 note). 13

9 What to bring to Brightside: A change of clothing, clearly labeled with client s name A sweater in case you get cold! Adult disposable underwear (if applicable) Medication as prescribed, in original bottles, along with doctor s orders Diabetes Supplies (for persons who are insulin dependent): test strips, glucometer, insulin, shakes, glucose tablets, syringes, sliding scale booklet, etc. Store-brought goodies (for special events like birthdays) Over-the-counter Medications Please note: The state of Illinois requires written authorization for the dispensing of non-aspirin pain relievers (such as Tylenol) by nursing staff to participants. If you need to take OTC meds during your time at Brightside, you must bring your own medication must be in a clearly labeled bottle AND, there must be an order from the doctor. What not to send to Brightside: Money! (Clients never need money at Brightside) Home-made goodies (we love them but can t eat them due to Health Dept. guidelines) Valuable items! Cell phones (may certainly bring them but there s really no time or need to use them we ask they be used in emergency only) Relatives! While it s fun to have family around, we do not allow family to stay on site. We encourage you to enjoy your respite! Three wheel scooters we just don t have room for them. We re Open! Please note that Brightside almost never closes due to weather! More often than not during bad weather such as a snow storm, we will cancel transportation but leave the center open. We will call you if we have to cancel transportation. When in doubt, please call us! A DAY AT LIFESCAPE BRIGHTSIDE: Arrival: a warm welcome and coffee 8:30 10:00 a.m. Breakfast is offered 7:30 11:00 a.m. Socialization, activities, games, cards, crafts 11 11:45 a.m. Exercise 11:45 12:30 p.m. Lunch 12:30 1:00 p.m. Discussion, conversation, current events, music 1:00 2:00 p.m. Something different every day, check our calendar! 2:00 2:30 p.m. Snack and socialization 2:30 5:30 p.m. Small group activities, table games, personal projects 9

10 Staying an Active Client: Requirements for Brightside Clients In order to make sure those who attend Brightside are appropriate, we follow guidelines. We do everything possible to ensure clients may remain in the program as long as possible, but there are times discharge or scheduled absence from the program is needed. Reasons someone might not be able to attend Brightside include but are not limited to: Client becomes bedfast Client does not have the strength or stamina to attend for six hours a day Client cannot sit up for at least 30 minutes at a time Client is in an infectious state of a communicable disease Client s behavior deteriorates to the point he/she is destructive to self or others or is severely disruptive in group setting or sexually inappropriate to staff or clients. Client improves to point they do not benefit from the activities. Client who becomes continuously bowel incontinent Client requires two person transfer Client is unable to assist staff when transferring (can t bear any weight) Client requires IV therapy while at center Client, caregivers and family agree that continued participation is no longer of benefit to the client Client is discharged to long term care or assisted living. 10 Reasons to stay home While we encourage all clients to attend Brightside as scheduled, there are times when it is important to stay home. GENERAL MEDICAL REASONS to stay home include: fever, diarrhea, flu and pneumonia. Please note: When a client develops symptoms such as fever or diarrhea while at Brightside, we have to send them home! SPECIAL MENTION SHINGLES: If you have shingles, please stay home until you are prescribed an antiviral medication and have a doctor s note to return. For everyone s safety, shingles must be covered and not weeping. MEDICAL CLEARANCE: We want you healthy! We request medical clearance from your doctor after medical episodes including but not limited to: heart attack; stroke (CVA); hospitalization; major surgery; visit to emergency room for symptoms displayed at Brightside; diagnosis of communicable diseases such as C- DIFF, TB or MRSA; extended absence related to medical issues. MAY WE SUGGEST: If laxatives are used, please do not return to Brightside until the laxative is done working! There s not much worse than the embarrassment of bowel incontinence at the center, especially on the bus. 11

BRIGHTSIDE ADULT DAY SERVICE INTAKE PACKET

BRIGHTSIDE ADULT DAY SERVICE INTAKE PACKET INTAKE PACKET : BRIGHTSIDE ADULT DAY SERVICE INTAKE PACKET Client Name: Address: City: DOB: Phone: Zip: SSN: Medicare: Medicaid: Other Entitlement (specify): Living Arrangement: Alone Spouse Partner Adult

More information

THE PAIN TREATMENT CENTER, INC. d/b/a STONE ROAD SURGERY CENTER

THE PAIN TREATMENT CENTER, INC. d/b/a STONE ROAD SURGERY CENTER THE PAIN TREATMENT CENTER, INC. d/b/a STONE ROAD SURGERY CENTER PATIENT INFORMATION GUIDE 280 Pasadena Drive Lexington, Kentucky 40503 (859) 278-1316 Visit us on the Web at www.pain-ptc.com Dear Patients

More information

The Good Samaritan Society CHOICE Program. Client Handbook. In Co-operation with Alberta Health Services

The Good Samaritan Society CHOICE Program. Client Handbook. In Co-operation with Alberta Health Services The Good Samaritan Society CHOICE Program Client Handbook In Co-operation with Alberta Health Services We Want to Hear from You We are committed to providing a high standard of care, tailored to fit your

More information

PATIENT SERVICES POLICY AND PROCEDURE MANUAL

PATIENT SERVICES POLICY AND PROCEDURE MANUAL SECTION Patient Services Manual Multidiscipline Section NAME Patient Rights and Responsibilities PATIENT SERVICES POLICY AND PROCEDURE MANUAL EFFECTIVE DATE 8-1-11 SUPERSEDES DATE 7-20-10 I. PURPOSE To

More information

ADULT LONG-TERM CARE SERVICES

ADULT LONG-TERM CARE SERVICES ADULT LONG-TERM CARE SERVICES Long-term care is a broad range of supportive medical, personal, and social services needed by people who are unable to meet their basic living needs for an extended period

More information

UPMC HOSPITAL DIVISION POLICY AND PROCEDURE MANUAL. SUBJECT: Patients' Notice and Bill of Rights and Responsibilities DATE: July 27, 2012

UPMC HOSPITAL DIVISION POLICY AND PROCEDURE MANUAL. SUBJECT: Patients' Notice and Bill of Rights and Responsibilities DATE: July 27, 2012 UPMC HOSPITAL DIVISION POLICY AND PROCEDURE MANUAL POLICY: HS-HD-PR-01 * INDEX TITLE: Patient Rights/ Organizational Ethics SUBJECT: Patients' Notice and Bill of Rights and Responsibilities DATE: July

More information

Patient Guide. Comfortable Place, Exceptional Care STATION. Outpatient Surgical Procedures. Surgical Center

Patient Guide. Comfortable Place, Exceptional Care STATION. Outpatient Surgical Procedures. Surgical Center Patient Guide Outpatient Surgical Procedures Comfortable Place, Exceptional Care TAYLOR STATION Surgical Center Welcome Thank you for selecting Taylor Station Surgical Center for your surgical procedure.

More information

Patient Rights and Responsibilities

Patient Rights and Responsibilities Developed / Edited By: UNION HOSPITAL Reviewed By: Approved By: Policy Number: AG-245 Elkton, Maryland Effective Date: 11/2009 Hospital Policies and Procedures Patient Rights and Responsibilities Departments

More information

Introduction to Day Hospital

Introduction to Day Hospital Introduction to Day Hospital Information for clients and their families 3G Day Hospital: 905-521-2100, ext. 72831 1 Introduction to Day Hospital Introduction to Day Hospital The Day Hospital on 3G is part

More information

Patient Rights and Responsibilities: Working Together to Ensure Remarkable Care EXPANDED VERSION

Patient Rights and Responsibilities: Working Together to Ensure Remarkable Care EXPANDED VERSION Patient Rights and Responsibilities: Working Together to Ensure Remarkable Care EXPANDED VERSION St. Joe s is committed to providing compassionate and respectful care. Your health care team will: Care

More information

Rehab Centers - Pediatric Specialty Therapy. Pediatric Outpatient Handbook

Rehab Centers - Pediatric Specialty Therapy. Pediatric Outpatient Handbook Rehab Centers - Pediatric Specialty Therapy Pediatric Outpatient Handbook Dear Patient/Parent, Thank you for choosing Hanover Hospital Rehab Centers Pediatric Specialty Therapy for your child s therapy/rehabilitation.

More information

LIVING WILL AND ADVANCE DIRECTIVES. Exercise Your Right: Put Your Healthcare Decisions in Writing

LIVING WILL AND ADVANCE DIRECTIVES. Exercise Your Right: Put Your Healthcare Decisions in Writing LIVING WILL AND ADVANCE DIRECTIVES Exercise Your Right: Put Your Healthcare Decisions in Writing Maryland Advance Directive A Message from the Maryland Attorney General Adults can decide for themselves

More information

LIVING WILL AND ADVANCE DIRECTIVES. Exercise Your Right: Put Your Healthcare Decisions in Writing.

LIVING WILL AND ADVANCE DIRECTIVES. Exercise Your Right: Put Your Healthcare Decisions in Writing. LIVING WILL AND ADVANCE DIRECTIVES Exercise Your Right: Put Your Healthcare Decisions in Writing. Maryland Advance Directive A Message from the Maryland Attorney General Adults can decide for themselves

More information

Advance Care Planning Communication Guide: Overview

Advance Care Planning Communication Guide: Overview Advance Care Planning Communication Guide: Overview The INTERACT Advance Care Planning Communication Guide is designed to assist health professionals who work in Nursing Facilities to initiate and carry

More information

Elder Care Services, Inc. Elder Day Stay N. Monroe Street Tallahassee, FL Telephone Fax

Elder Care Services, Inc. Elder Day Stay N. Monroe Street Tallahassee, FL Telephone Fax Elder Care Services, Inc. Elder Day Stay 1660-11 N. Monroe Street Tallahassee, FL 32303 Telephone 850-222-4208 Fax 850-222-0330 Overview of Program Elder Day Stay is sponsored by Elder Care Services. The

More information

Alabama Medicaid Adult Day Health Minimum Standards

Alabama Medicaid Adult Day Health Minimum Standards Alabama Medicaid Adult Day Health Minimum Standards ADH = Adult Day Health E/D = Elderly & Disabled AMA = Alabama Medicaid Agency Local Area Agency on Aging = SARCOA I. Adult Day Health Services: A. Definition:

More information

Welcome to LifeWorks NW.

Welcome to LifeWorks NW. Welcome to LifeWorks NW. Everyone needs help at times, and we are glad to be here to provide support for you. We would like your time with us to be the best possible. Asking for help with an addiction

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care

More information

Medical and Surgical Intensive Care Units (MICU/SICU)

Medical and Surgical Intensive Care Units (MICU/SICU) Medical and Surgical Intensive Care Units (MICU/SICU) Welcome Having a loved one in the Medical and Surgical Intensive Care Unit (MICU/SICU) can be overwhelming. Our goal is to provide you with expert

More information

Cardiothoracic Intensive Care Unit (CTICU)

Cardiothoracic Intensive Care Unit (CTICU) Cardiothoracic Intensive Care Unit (CTICU) Welcome Having a loved one in the Intensive Care Unit (ICU) can be overwhelming. Our goal is to provide you with expert patient care in a comfortable and family-centered

More information

mobility plus application package SECTION A: For completion by applicant

mobility plus application package SECTION A: For completion by applicant SECTION A: For completion by applicant York Region s shared ride, door-to-door, accessible public transit service for people with disabilities mobility plus application package Mobility Plus Application

More information

Patient s Bill of Rights (Revised April 2012)

Patient s Bill of Rights (Revised April 2012) Patient s Bill of Rights (Revised April 2012) TIRR Memorial Hermann recognizes the rights of human beings for independence of expression, decision, and action and will protect these rights of all patients,

More information

Fairfax Surgical Center. Statement of Patient Rights and Responsibility

Fairfax Surgical Center. Statement of Patient Rights and Responsibility Fairfax Surgical Center Statement of Patient Rights and Responsibility PATIENT RIGHTS The Fairfax Surgical Center (ASC) respects the dignity and pride of each individual we serve. Every patient has the

More information

Resident Rights in Nursing Facilities

Resident Rights in Nursing Facilities Your Guide to Resident Rights in Nursing Facilities 1-800-499-0229 1 Table of Contents The Ombudsman Advocate...3 You Take Your Rights with You...4 Federal Regulations Protect You...5 Medical Assessment

More information

Goodwill Adult Day Care 923 Hilltop Drive, Lawton, OK 73507

Goodwill Adult Day Care 923 Hilltop Drive, Lawton, OK 73507 Goodwill Adult Day Care 923 Hilltop Drive, Lawton, OK 73507 Phone: 580-248-9313, Fax: 580-248-4202 PARTICIPANT S INTAKE INFORMATION SHEET NAME: ADDRESS: ZIP: PHONE: SOCIAL SECURITY NUMBER: DATE OF BIRTH:

More information

Fultondale Elementary After School Care & Summer Program

Fultondale Elementary After School Care & Summer Program Fultondale Elementary After School Care & Summer Program Child Care Handbook Fultondale Elementary (205) 285-4904 Community School Office: Phone (205)379-5650 Fax (205)379-5652 Kay Sharp - Zone Coordinator

More information

*3ADV* Patient Rights & Responsibilities Advanced Directive Page 1 of 2. Patient Rights & Responsibilities. Patient Label

*3ADV* Patient Rights & Responsibilities Advanced Directive Page 1 of 2. Patient Rights & Responsibilities. Patient Label PATIENT RIGHTS Portneuf Medical Center encourages respect for the personal preferences and values of each individual and supports the Rights of each patient and resident of the Center, or their representative

More information

A GUIDE TO THE CRANBERRY CAMPUS EMERGENCY DEPARTMENT

A GUIDE TO THE CRANBERRY CAMPUS EMERGENCY DEPARTMENT A GUIDE TO THE CRANBERRY CAMPUS EMERGENCY DEPARTMENT WELCOME TO UPMC PASSAVANT-CRANBERRY EMERGENCY DEPARTMENT The staff at UPMC Passavant-Cranberry would like to make your visit with us as easy and comfortable

More information

Patient rights and responsibilities

Patient rights and responsibilities Patient rights and responsibilities (Also: Billing FAQs) Legacy Health Patient Information: Rights/Responsibilities, It s OK to Ask, Billing FAQs 1 Patient rights and responsibilities Your hospital experience

More information

Long-Term Services and Support (LTSS) Handbook. Blue Cross Community ICPSM

Long-Term Services and Support (LTSS) Handbook. Blue Cross Community ICPSM Blue Cross Community ICPSM Long-Term Services and Support (LTSS) Handbook Effective March 2014 www.bcbsilcommunityicp.com Call Toll Free: 1-888-657-1211 TTY/TDD 711. We are open between 8 a.m. to 8 p.m.

More information

Ridgeline Endoscopy Center Patient Rights and Responsibilities

Ridgeline Endoscopy Center Patient Rights and Responsibilities Ridgeline Endoscopy Center Patient Rights and Responsibilities PATIENT RIGHTS Ridgeline Endoscopy Center respects the dignity and pride of each individual we serve. Every patient has the right to have

More information

A Guide to the Emergency Department

A Guide to the Emergency Department A Guide to the Emergency Department Welcome to UPMC Mercy Emergency Department The staff at UPMC Mercy would like to make your visit with us as easy and comfortable as possible. Please read through this

More information

Methodist Ambulatory Surgery Center-Medical Center Statement of Patient Rights and Responsibilities

Methodist Ambulatory Surgery Center-Medical Center Statement of Patient Rights and Responsibilities Methodist Ambulatory Surgery Center-Medical Center Statement of Patient Rights and Responsibilities PATIENT RIGHTS We respect the dignity and pride of each individual we serve. We comply with applicable

More information

MAKING YOUR WISHES KNOWN: Advance Care Planning Guide

MAKING YOUR WISHES KNOWN: Advance Care Planning Guide MAKING YOUR WISHES KNOWN: Advance Care Planning Guide ADVANCE CARE PLANNING The process of learning about the type of medical decisions that may need to be made, considering those decisions ahead of time

More information

Patient Rights & Responsibilities

Patient Rights & Responsibilities Patient & ESRD Network 18 of Southern California presents this page of patient rights and responsibilities as an important part of your care. Observing them will contribute to more effective care and greater

More information

We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.

We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Appointment Date: Appointment Time: Dear Orion Member, We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Enclosed

More information

APPENDIX I HOSPICE INPATIENT FACILITY (HIF)

APPENDIX I HOSPICE INPATIENT FACILITY (HIF) INTRODUCTION APPENDIX I HOSPICE INPATIENT FACILITY (HIF) The principles and standards in all chapters of the Standards of Practice for Hospice Programs apply to hospice care provided in an inpatient facility.

More information

Safety, Comfort, and Well-being

Safety, Comfort, and Well-being POLICIES AND PROCEDURES MANUAL NORTH END SENIOR SOLUTIONS ADULT DAY SERVICE (ADS) THE NESS CLUB Safety, Comfort, and Well-being Revised October 20, 2017 jmf Jan Molnar Fitzgerald, Exec Dir. Model: VA Tech

More information

Documenting and Reporting

Documenting and Reporting Duty: Communicate Client Information to Authorized Persons Task : E.01 Report abuse of client E.02 Report client s unusual behavior E.03 Complete incident report E.05 Respond to authorized persons request

More information

EASTERN MIDDLE SCHOOL POLICIES AND PROCEDURES

EASTERN MIDDLE SCHOOL POLICIES AND PROCEDURES EASTERN MIDDLE SCHOOL POLICIES AND PROCEDURES ACADEMIC HONESTY All work turned in by a student should be his or her own work, reflecting what the student has learned. Using someone else s work, words,

More information

A Guide to Your Surgery

A Guide to Your Surgery A Guide to Your Surgery A Guide to Your Surgery at UPMC Northwest Welcome to UPMC Northwest and thank you for choosing our hospital for your health care needs. Your care revolves around our values: Quality

More information

ACCESS CENTRE. FHAC Intake Coordinator Phone: Toll Free: Fax:

ACCESS CENTRE. FHAC Intake Coordinator Phone: Toll Free: Fax: ACCESS CENTRE Five Hills Access Centre (FHAC) is a single point of entry for all Continuing Care Services including Home Care, Long Term Care, Palliative Care, Respite Care and Transition Care. FHAC Intake

More information

Informed Consent for Treatment

Informed Consent for Treatment Informed Consent for Treatment TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended diagnostic, physical therapy or rehabilitation treatment/procedure

More information

Roger A. Olsen, Psy.D., L.P Slater Road, Suite 210 Eagan, MN Phone: FAX:

Roger A. Olsen, Psy.D., L.P Slater Road, Suite 210 Eagan, MN Phone: FAX: Roger A. Olsen, Psy.D., L.P. 4660 Slater Road, Suite 210 Eagan, MN 55122 Phone: 651-882-6299 FAX: 651-683-0057 INFORMATION FOR NEW CLIENTS Welcome to my practice. This document contains important information

More information

QUALITY OF LIFE ASSESSMENT RESIDENT INTERVIEW

QUALITY OF LIFE ASSESSMENT RESIDENT INTERVIEW DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION QUALITY OF LIFE ASSESSMENT RESIDENT INTERVIEW Facility Name: Provider Number: Surveyor Name: Surveyor Number: Discipline: Resident

More information

A Guide to Your Surgery

A Guide to Your Surgery A Guide to Your Surgery A Guide to Your Surgery at UPMC East Welcome to UPMC East and thank you for choosing our hospital to provide your health care services. Our care revolves around our values: Dignity

More information

Pre-Operative Surgical Packet

Pre-Operative Surgical Packet Pre-Operative Surgical Packet We know that you have many questions about your surgery and what to expect. The following pages contain answers to the questions most commonly asked by our patients and their

More information

A Guide to Your Surgery

A Guide to Your Surgery A Guide to Your Surgery A Guide to Your Surgery at Magee-Womens Hospital of UPMC Welcome to Magee and thank you for choosing our hospital for your health care needs. Your care revolves around our values:

More information

Maidstone Home Care Limited

Maidstone Home Care Limited Maidstone Home Care Limited Maidstone Home Care Limited Inspection report Home Care House 61-63 Rochester Road Aylesford Kent ME20 7BS Date of inspection visit: 19 July 2016 Date of publication: 15 August

More information

Sandra V Heinsz, Ph.D. Informed Consent Services Agreement

Sandra V Heinsz, Ph.D. Informed Consent Services Agreement Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance

More information

Non-Emergency Medical Transportation

Non-Emergency Medical Transportation Non-Emergency Medical Transportation Last Updated: April 18, 2018 This a guide for healthcare facilities requesting nonemergency medical transportation on behalf of HUSKY Health members in the State of

More information

Welcome DAVIS 7 PEDIATRICS

Welcome DAVIS 7 PEDIATRICS Welcome DAVIS 7 PEDIATRICS Welcome to Davis 7 Pediatrics We believe it is very important for you to participate in your child s care. No one knows your child better than you and we want to learn what works

More information

Parent & Guardian Handbook

Parent & Guardian Handbook Parent & Guardian Handbook 1 We are pleased to welcome you to Canton Parks and Recreation and to offer exciting programs and activities for the upcoming summer season. You will find the answers to most

More information

Let s TALK about... Patient Rights and Responsibilities

Let s TALK about... Patient Rights and Responsibilities Let s TALK about... Patient Rights and Responsibilities What you should know about your Rights and Responsibilities Communication and Decision Making To know the name, role, and specialty of all people

More information

THE DAY OF YOUR SURGERY

THE DAY OF YOUR SURGERY Patient Guide Welcome Rockford Ambulatory Surgery Center provides a high-quality, convenient and comfortable setting for many outpatient surgical procedures. Your preparation and cooperation are important

More information

Non-Emergency Medical Transportation

Non-Emergency Medical Transportation HOW TO REQUEST Non-Emergency Medical Transportation This a guide on how to use the transportation benefits offered by the HUSKY Health Program Table of Contents Important Resources 3 What Is NEMT? 3 Who

More information

Appendix 2 Community Based Residential Facility

Appendix 2 Community Based Residential Facility Appendix 2 Community Based Residential Facility Scope of Service The provision of services to members in a Community Based Residential Facility (CBRF) is for purposes of providing needed care or support

More information

MARYLAND Advance Directive Planning for Important Healthcare Decisions

MARYLAND Advance Directive Planning for Important Healthcare Decisions MARYLAND Advance Directive Planning for Important Healthcare Decisions Caring Info 1731 King St, Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Info, a program of the National Organization

More information

Karen LeVasseur, LCSW Calm4Kids Therapy Center, LLC 514 Main Street Bradley Beach, NJ

Karen LeVasseur, LCSW Calm4Kids Therapy Center, LLC 514 Main Street Bradley Beach, NJ Karen LeVasseur, LCSW Calm4Kids Therapy Center, LLC 514 Main Street Bradley Beach, NJ 07720 732 272 8624 THERAPIST CLIENT SERVICE AGREEMENT/INFORMED CONSENT Welcome to my practice. This document contains

More information

MARYLAND ADVANCE DIRECTIVE PLANNING FOR FUTURE HEALTH CARE DECISIONS

MARYLAND ADVANCE DIRECTIVE PLANNING FOR FUTURE HEALTH CARE DECISIONS MARYLAND ADVANCE DIRECTIVE PLANNING FOR FUTURE HEALTH CARE DECISIONS A guide to Maryland Law on Health Care Decisions (Forms Included) State of Maryland Office of the Attorney General Dear Fellow Marylander:

More information

Appendix 2 Corporate Adult Family Homes

Appendix 2 Corporate Adult Family Homes Appendix 2 Corporate Adult Family Homes SCOPE OF SERVICE The service is a non-owner occupied Adult Family Home in which 1 4 adults, not related to the licensee reside. Care, treatment or services above

More information

OUTPATIENT SERVICES CONTRACT 2018

OUTPATIENT SERVICES CONTRACT 2018 1308 23 rd Street S Fargo, ND 58103 Phone: 701-297-7540 Fax: 701-297-6439 OUTPATIENT SERVICES CONTRACT 2018 Welcome to Benson Psychological Services, PC. This document contains important information about

More information

Your Rights and Responsibilities as a Patient at Sparrow Hospital

Your Rights and Responsibilities as a Patient at Sparrow Hospital Your Rights and Responsibilities as a Patient at Sparrow Hospital Sparrow s mission is to improve the health of the people in our communities by providing quality, compassionate care to every person, every

More information

NAPERVILLE SENIOR CENTER MEMBER INFORMATION

NAPERVILLE SENIOR CENTER MEMBER INFORMATION NAPERVILLE SENIOR CENTER MEMBER INFORMATION Member Name: Address: City: SSN: Long Term Insurance: DOB: Home Phone: Cell Phone: Zip: Email Address: Other Entitlement (specify): Living Arrangement: Alone

More information

MARYLAND Advance Directive Planning for Important Healthcare Decisions

MARYLAND Advance Directive Planning for Important Healthcare Decisions MARYLAND Advance Directive Planning for Important Healthcare Decisions Caring Connections 1731 King St, Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program of

More information

Volunteer Application

Volunteer Application 333 Fourth Street Marietta, OH 45750 Phone (740) 373-3914 Fax (740) 373-8191 www.oneillcenter.com Volunteer Application Personal Data Date Name Address Phone (Day) City, State, Zip (Night) Date of Birth

More information

Golden Years Care Home

Golden Years Care Home Mrs M C Prenger Golden Years Care Home Inspection report 47-49 Shaftesbury Avenue Blackpool Lancashire FY2 9TW Tel: 01253594183 Date of inspection visit: 10 January 2018 Date of publication: 05 February

More information

Champlain Community Care Access Centre

Champlain Community Care Access Centre Champlain Community Care Access Centre What s inside: Welcome to the Champlain CCAC What Can I Expect From the CCAC? Nursing Clinics and Community Services Alternatives to Care at Home Your Rights and

More information

ADVANCE DIRECTIVES. Living Will And Durable Power of Attorney for Healthcare

ADVANCE DIRECTIVES. Living Will And Durable Power of Attorney for Healthcare ADVANCE DIRECTIVES Living Will And Durable Power of Attorney for Healthcare Revised: BW/Sept. 2010 Revised: BW/September 2010 Advance Directives It is the belief of Trinitas Regional Medical Center that

More information

A Guide to Your Surgery

A Guide to Your Surgery A Guide to Your Surgery A Guide to Your Surgery at UPMC Bedford Welcome to UPMC Bedford and thank you for choosing our hospital for your health care needs. Your care revolves around our values: Quality

More information

TrainingABC Patient Rights Made Simple Support Materials

TrainingABC Patient Rights Made Simple Support Materials TrainingABC 2017 Patient Rights Made Simple Support Materials Video Transcript The Patient Bill of Rights is a list of rights first developed in 1973 and then revised in 1992, by the American Hospital

More information

SHELTER PLUS CARE REFERRAL/APPLICATION PACKET

SHELTER PLUS CARE REFERRAL/APPLICATION PACKET SHELTER PLUS CARE REFERRAL/APPLICATION PACKET Updated August 2016 Applicant s Name: Date: Referral Source: Received Date: Staff: Fairview Recovery Services helps people with the disease of alcoholism,

More information

FLOYD Patient Rights & Responsibilities Nondiscrimination and Accessibility Derechos y Responsabilidades de los Pacientes

FLOYD Patient Rights & Responsibilities Nondiscrimination and Accessibility Derechos y Responsabilidades de los Pacientes FLOYD Patient Rights & Responsibilities Nondiscrimination and Accessibility Derechos y Responsabilidades de los Pacientes Copias en espanol a peticion As a patient of Floyd Medical Center or Willowbrooke

More information

Patient Rights and Responsibilities

Patient Rights and Responsibilities Patient Rights and Responsibilities Your patient rights Swedish wants you to be aware of your rights as a patient. We will do everything possible to make sure that your rights are respected. As a patient

More information

Long Term Care in British Columbia Residential Facilities GOVERNMENT-SUBSIDIZED NURSING HOMES. How Nursing Homes are Organized and Administered

Long Term Care in British Columbia Residential Facilities GOVERNMENT-SUBSIDIZED NURSING HOMES. How Nursing Homes are Organized and Administered Long Term Care in British Columbia 2016 Residential Facilities GOVERNMENT-SUBSIDIZED NURSING HOMES How Nursing Homes are Organized and Administered Nursing homes/residential facilities provide 24-hour

More information

Medical History Form

Medical History Form Medical History Form Patient Name of Birth Medical History Do you have or have you had any of the following? Condition Yes No Condition Yes No Condition Yes No ADHD Stroke Menopausal Syndrome Allergies

More information

Westchester Medical Center BEHAVIORAL HEALTH CENTER

Westchester Medical Center BEHAVIORAL HEALTH CENTER 1 Westchester Medical Center BEHAVIORAL HEALTH CENTER 2 Welcome to the Behavioral Health Center of Westchester Medical Center. Our staff is committed to providing you with outstanding care and service

More information

Immunizations Criminal Background check Infection Control HIPPA Health Insurance Portability and Accountability Act

Immunizations Criminal Background check Infection Control HIPPA Health Insurance Portability and Accountability Act Reedsburg Area Senior Life Center Welcome to Reedsburg Area Senior Life Center for your clinical! We hope you will have a positive and rewarding learning experience. If you have any questions during your

More information

Radis Community Care (Nottingham)

Radis Community Care (Nottingham) G P Homecare Limited Radis Community Care (Nottingham) Inspection report 12A Chilwell Road Beeston Nottingham Nottinghamshire NG9 1EJ Date of inspection visit: 08 August 2017 Date of publication: 14 September

More information

MARYLAND ADVANCE DIRECTIVE: PLANNING FOR FUTURE HEALTH CARE DECISIONS

MARYLAND ADVANCE DIRECTIVE: PLANNING FOR FUTURE HEALTH CARE DECISIONS MARYLAND ADVANCE DIRECTIVE: PLANNING FOR FUTURE HEALTH CARE DECISIONS A Guide to Maryland Law on Health Care Decisions (Forms Included) STATE OF MARYLAND OFFICE OF THE ATTORNEY GENERAL Douglas F. Gansler

More information

PO Box 350 Willimantic, Connecticut (860) Connecticut Ave, NW Suite 709 Washington, DC (202)

PO Box 350 Willimantic, Connecticut (860) Connecticut Ave, NW Suite 709 Washington, DC (202) PO Box 350 Willimantic, Connecticut 06226 (860)456-7790 1025 Connecticut Ave, NW Suite 709 Washington, DC 20036 (202)293-5760 Se habla español Produced under a grant from the Connecticut State Department

More information

Hospital Administration Manual

Hospital Administration Manual PATIENT RIGHTS POLICY Hospital Administration Manual Effective Date: PC-33 HAM 5/1/2017 PURPOSE At the Milton S. Hershey Medical Center (MSHMC), our goal is to provide excellent health care to every patient.

More information

Psychological Services Agreement

Psychological Services Agreement John A. Watterson, Ph.D. 4101 Parkstone Heights Drive, Suite 260 Austin, Texas 78746 Phone: 512-306-0663 Fax: 512-306-8086 Website: www.johnwatterson.com Psychological Services Agreement Welcome to my

More information

2018 CAMP Registration Packet. Boyertown YMCA PHILADELPHIA FREEDOM VALLEY YMCA

2018 CAMP Registration Packet. Boyertown YMCA PHILADELPHIA FREEDOM VALLEY YMCA 2018 CAMP Registration Packet Boyertown YMCA PHILADELPHIA FREEDOM VALLEY YMCA 1 Camp Registration Procedures 1. The entire camp registration packet minus the (optional) Request for Modification and Diabetes

More information

THE COMMONWEALTH OF MASSACHUSETTS Department of Early Education and Care

THE COMMONWEALTH OF MASSACHUSETTS Department of Early Education and Care THE COMMONWEALTH OF MASSACHUSETTS Department of Early Education and Care Group and School Age Child Care Licensing TECHNICAL ASSISTANCE: Writing Program Policies All of the situations which any parent

More information

A Guide to Your Surgery

A Guide to Your Surgery A Guide to Your Surgery A Guide to Your Surgery at UPMC McKeesport Welcome to UPMC McKeesport and thank you for choosing our hospital to provide your health care services. Our care revolves around our

More information

General information guide

General information guide Patient information General information guide i Important general information for all patients. Golden Jubilee National Hospital Agamemnon Street Clydebank, G81 4DY (: 0141 951 5000 www.nhsgoldenjubilee.co.uk

More information

Initial Pool Process: Resident Interview

Initial Pool Process: Resident Interview Initial Pool Process: Resident Interview Care Area Probes Response Options Choices Are you able to make choices about your daily life that are important to you? I d like to talk to you about your choices.

More information

Signature (Patient or Legal Guardian): Date:

Signature (Patient or Legal Guardian): Date: X-Ray Patient Information: [ ] Male [ ] Female Patient Name: Date of Birth: / / SS#: Mailing Address: City: State: Zip: Phone # s: (Home) (Work) (Cell) Referring Physician: Phone #: /Fax#: Additional Physician:

More information

2 North Meridian Street Indianapolis, Indiana March 1999 Revised May 2004 ADVANCE DIRECTIVES YOUR RIGHT TO DECIDE

2 North Meridian Street Indianapolis, Indiana March 1999 Revised May 2004 ADVANCE DIRECTIVES YOUR RIGHT TO DECIDE 2 North Meridian Street Indianapolis, Indiana 46204 March 1999 Revised May 2004 ADVANCE DIRECTIVES YOUR RIGHT TO DECIDE The purpose of this brochure is to inform you of ways that you can direct your medical

More information

Important: Drivers must see you! Volunteer Safety Policies

Important: Drivers must see you! Volunteer Safety Policies Volunteer Safety Policies Pets Please confine, leash or move pets to a separate area during the delivery time of 11:15am to 12:30pm. Appropriate Clothing You must be appropriately clothed during the delivery

More information

Visiting Northwestern Medicine Central DuPage Hospital

Visiting Northwestern Medicine Central DuPage Hospital Visiting Northwestern Medicine Central DuPage Hospital Northwestern Medicine Central DuPage Hospital 25 North Winfield Road Winfield, Illinois 60190 630.933.1600 TTY for the hearing impaired 630.933.4833

More information

Liberty House Care Homes

Liberty House Care Homes Liberty House Care Home Limited Liberty House Care Homes Limited Inspection report 55 Copeley Hill, Erdington, Birmingham, B23 7PH Tel: 0121 3270671 Website: Date of inspection visit: To Be Confirmed Date

More information

Computers for Visitor Use. Tips. Coffee Shop. Dining. Do Not Use Cell Phone. Restrooms. Gift Shop. Chapel. Parking.

Computers for Visitor Use. Tips. Coffee Shop. Dining. Do Not Use Cell Phone. Restrooms. Gift Shop. Chapel. Parking. Journey to Wellness Welcome to UPMC Presbyterian Thank you for choosing UPMC for your care today. The hospital staff is dedicated to ensuring that your surgery goes well. We value excellence in patient

More information

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name Patient Information 2201 Murphy Avenue, Suite 307 Nashville, TN 37203 Phone 615-401- 9454 Fax 615-873- 1934 www.robbinsplasticsurgery.com Date Patient s Full Name Last First M.I. Preferred Name (if different

More information

A Helping Hand. Navigating your way in your new home. (Personal Care Home Edition)

A Helping Hand. Navigating your way in your new home. (Personal Care Home Edition) A Helping Hand Navigating your way in your new home (Personal Care Home Edition) Name: Phone Number: Home Administrator Name: Phone Number: Local Ombudsman Name: Phone Number: PEER Contact All communication

More information

Last Name: First Name: Advance Directive including Power of Attorney for Health Care

Last Name: First Name: Advance Directive including Power of Attorney for Health Care Patient Medical Record Number: Or Label Advance Directive including Power of Attorney for Health Care Overview This legal document meets the requirements for Wisconsin.* It lets you Name another person

More information

Supporting pupils at school with medical conditions Policy

Supporting pupils at school with medical conditions Policy KENILWORTH SCHOOL & SIXTH FORM Supporting pupils at school with medical conditions Policy JUNE 2016 POLICY DETAILS Date of policy: April 2016 Date of review: April 2017 Member of staff responsible for

More information

LICENSED CLINICAL SOCIAL WORKER-PATIENT SERVICES AGREEMENT

LICENSED CLINICAL SOCIAL WORKER-PATIENT SERVICES AGREEMENT LICENSED CLINICAL SOCIAL WORKER-PATIENT SERVICES AGREEMENT PLEASE KEEP THIS DOCUMENT FOR YOUR RECORDS Welcome to our practice. This document (the Agreement) contains important information about my professional

More information

Attachment N RESPITE SERVICE MANUAL

Attachment N RESPITE SERVICE MANUAL RESPITE SERVICE MANUAL 1 RESPITE WORKER 1. SCHEDULING Scheduling of the respite worker is done by the Respite Office ( Respite ). Parents or guardians of the clients hereinafter referred to as Parent(s)/Guardians

More information