Patient Name: I.D. Number: Section A: Identifying Proper Payor ADMISSION CONSENTS Are services provided to you by Hospice reimbursements through health insurance other than Medicare due to one of the following situations? 1. Yes No Automobile Medical or No Fault insurance due to an accident? 2. Yes No Patient 65 or older, but employed and covered by Employee Group Health Plan, or spouse of any age employed and covered by Employee Group Health Plan? 3. Yes No Patient under 65, but covered under Employee Group Health Plan due to End Stage Renal Disease? 4. Yes No Patient injury/illness is job related and covered under Workers Compensation? 5. Yes No Patient covered under the Federal Black Lung Program or Veterans Administration? 6. Yes No Patient under 65, entitled to Medicare solely on the basis of disability, considered an active employee and covered by a Large Group Health Plan or has a family member (parent, spouse, etc.) who is employed and covered by a Large Group Health Plan? 7. Yes No Have you/spouse signed up for a Medicare program that pays for your prescriptions under a Medicare HMO? IF YOUR RESPONSE TO ANY QUESTIONS ABOVE IS YES, OR IF YOU DO NOT HAVE MEDICARE, PLEASE COMPLETE THE FOLLOWING: 1. Name of Insurance Company: Phone 2. Name of Insured: 3. Patient s Relation to the Insured: 4. Claim or Policy Number: 5. Address of Insurance Company: 6. Insurance Group Identification Number:
7. Employer s Name: 8. Employer s Address: 9. Is Employee Full-time or Part-time: Retirement date of Patient: Retirement date of Spouse: Patient s Medicare Number: CHECK APPROPRIATE PAYOR SOURCE: IF MEDICARE ELIGIBLE: I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize release of all records required to act on this request. I request payment of authorized benefits be made in my behalf IF MEDICAID ELIGIBLE: I certify that the information given by me for payment under Medicaid is correct. IF PRIVATE INSURANCE: I certify that the information given by me in applying for services by Valley Hospice, Inc. is correct. I request that payment of authorized benefits be made in my behalf to Valley Hospice, Inc. I will be responsible for any payment of services not covered by my insurance. I authorize release of all records to my insurance carried to act on this request.
Section B: Consent for Care I,_, having received written information specifying the type of care and services that may be provided to me, hereby consent to admission and care by Valley Hospice, Inc. I acknowledge and understand the following: 1. Hospice care is palliative and not curative. The Hospice staff will work to alleviate symptoms I may experience, such as pain, nausea, or constipation. An interdisciplinary team consisting of my physician, a Medical Director, registered nurses, hospice aides, social workers, clergy, and other professionals will treat the physical, psychosocial, and spiritual needs I may experience. 2. Hospice care is not intended to take the place of either my family or my attending physician. The Hospice Team will support, educate, and assist my family in caring for me. They will provide consultation and direct pain and symptom control services as requested by my primary physician. 3. I understand that will be considered my primary caregiver. This means that he/she will be the person mainly responsible for looking after me in my home as instructed by the Hospice Team. 4. I understand that care will be provided by pre-arranged appointments, but that assistance is available 24 hours/day. 5. I understand that as long as I am enrolled in this hospice program, the Hospice Team of caregivers will manage my care whether I am being cared for in my home, a hospital, or a nursing home. 6. I understand that the hospice medical record will contain information about me, my family, and/or the primary caregiver. Every effort will be made to keep this information confidential. Information about me will be exchanged with my family. 7. I understand that if I am to receive full benefits of hospice care, it is important for me to make needs and concerns known to the hospice team. I will actively participate in plans for my care. 8. I understand that my care will be discussed at a weekly team meeting which I or my family are free to attend if we so desire. 9. I understand that I may withdraw consent to hospice care at anytime. 10. I understand that a home visit from surveyors may be requested for purpose of hospice licensure, certification, or accreditation, and I hereby give authorization for such a visit. However, I can always choose not to participate and my care will not be affected. 11. I have received written information about my rights regarding advance directives. I understand that lack of an advance directive will not affect the care I receive. I am not eligible for Medicare Part A. I understand that the statements regarding the Medicare Hospice Benefit do not apply to me. Insurance Coverage: I understand that my insurance,, projects that % of my Valley Hospice charges will be covered after my deductible is met. I understand that my insurance,, has not yet projected what percentage of my Valley Hospice charges will be covered. Projected insurance payment amounts will be provided, in writing, when the insurance company confirms that information with Valley Hospice. Private Pay: See per visit/per day rate sheet. Medicaid: Projected 100% coverage after meeting spend down and/or other requirement. Any non-covered charges will be assessed on a sliding scale fee basis. Medicaid Pending: If approved, Valley Hospice will pay as indicated above for Medicaid coverage. Patient and/or MPOA is responsible for all follow up with the Medicaid application. If denied, patient becomes a private pay patient and is responsible for payment of all medications, labs, and physician visits. I am eligible for Medicare Part A, projected 100% coverage. I authorize Hospice Medicare coverage to begin on according to the following statements: Month/Day/Year
1. I understand that by signing this Election Statement, I am choosing to receive the Hospice Medicare Benefit, which has been explained to me in full detail, in place of regular Medicare for my terminal illness. 2. The Medicare Benefit is broken down into benefit periods: First benefit period 90 days, second benefit period 90 days, and unlimited 60 day periods. 3. I can choose not to continue Hospice care at anytime. To discontinue services, I must complete a revocation statement, which can be obtained from any employee. 4. If I revoke my Hospice Medicare Benefit in the middle of a benefit period, I give up the remaining days in that benefit period. I would then have the subsequent periods and days for future use if I would so desire. 5. I understand that I will l need to be recertified at the end of each benefit period by a physician to ensure my eligibility for the next benefit period. 6. I understand that any lab work, X-rays, equipment, supplies, medications, treatments, and/or hospitalizations must be coordinated between my physician and Valley Hospice to be covered in full under the Hospice Medicare Benefit. 7. I further understand that failure to comply with the above will result in accepting financial responsibility for those services. 8. Medicare continues to cover treatment for conditions not related to the terminal illness, under regular Medicare. 9. I can choose to receive Hospice care from another Hospice program at anytime.
FINANCIAL - to be informed of the extent to which payment may be expected from Medicare, Medicaid, or any other payor known to the hospice organization; - to be informed of any charges that will not be covered by Medicare; - to receive this information orally and in writing, within fifteen working days of the date the hospice organization becomes aware of any changes in charges; - to have access, upon request, to all bills for services the patient has received regardless of whether they are paid out-of-pocket or by another party; - to be informed of the hospice s ownership status and its affiliation with any entities to whom the patient is referred. PATIENTS AND PROVIDERS HAVE A RIGHT TO DIGNITY AND RESPECT - Patients and their hospice caregivers have a right to mutual respect and dignity. Caregivers are prohibited from accepting personal gifts and borrowing from patients, families, and primary caregivers. - to have relationships with the hospice organization that are based on honesty and ethical standards of conduct; - To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is performing services on behalf of hospice. To lodge complaints with us, call the following office: Northern Office at (740) 284-4440 or Toll Free at 1-877-467-7423 Central Office at (740) 859-5650 Toll Free at 1-877-467-7423 Southern Office at (304) 242-1977 or Toll Free at 1-877-242-1977 If you have problems which you are unable to resolve with our office, you may make a complaint to the office of licensure and certification by calling 1-800-HHA-2888 in West Virginia or 1-800-342-0553 in Ohio or call Community Health Accreditation Program (CHAP) at 1-800-656-9656 24 hours a day, 7 days a week. Further, any person with reason to believe that an incapacitated adult is in an abusive or neglectful situation should notify adult protective services. Health care providers are required to report such circumstances. Any person making such a report in good faith is exempt from civil or criminal liability. - to know about the disposition of such complaints. - to voice their grievances without fear of discrimination or reprisal for having done so. I have received a copy of the Valley Hospice Notice of Privacy Practices explaining the privacy policies of the organization. I certify that all information given by me for identification of the proper payor is correct. I understand my rights as stated. I give consent for care by Valley Hospice. Patient s Signature: PCG s Signature: Witness s Signature: Date: Date: Date:
Section C: Bill of Rights Patients have a right to be informed verbally and in writing of their rights and obligations before their hospice care begins. Consistent with state laws, the patient s family or guardian may exercise the patient s rights when the patient is unable to do so. Hospice organizations have an obligation to protect and promote the rights of their patients, including the following: PATIENTS HAVE THE RIGHT: - to receive care of the highest quality without discrimination as to age, race, religion, sex, national origin, sexual orientation, color, disability, or creed; - in general, to be admitted by a hospice organization only if it is assured that all necessary palliative and supportive services will be provided which are necessary to promote the physical, psychological, social, and spiritual well being of the dying patient; however, an organization with less than optimal resources may nevertheless admit the patient if a more appropriate hospice organization is not available, but only after fully informing the client of its limitation and the lack of suitable alternative arrangements; - to exercise his/her rights as a patient of hospice; - to not be subjected to discrimination or reprisal for exercising their rights; - to be told what to do in the case of an emergency; - to receive effective pain management and symptom control from hospice for conditions related to the terminal illness; - to have property and person treated with respect; - to be free from mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source and misappropriation of patient property; - to receive information about the services covered under the hospice benefit; - to receive information about the scope of services that will be provided and specific limitations on those services The hospice organization shall assure that: - all medically related hospice care is provided in accordance with physician s orders and that a plan of care which is developed by the patient s physician and the hospice interdisciplinary group specifies the services to be provided and their frequency and duration; and - all medically related personal care is provided by an appropriately trained homemaker-hospice aide who is supervised by a registered nurse DECISION MAKING - to make their own medical treatment decisions; - to choose their attending physician; - to be notified in writing of the care that is to be furnished, the types (disciplines) of the caregivers who will furnish the care, and the frequency of the services that are proposed to be furnished; - to be advised of any change in the plan of care before the change is made; - to participate in the planning of the care and in planning changes in the care, and to be advised that they have the right to do so; - to refuse care or treatment and to be advised of the consequences of refusing care; - to request a change in caregiver without fear of reprisal or discrimination; - to examine their records at reasonable times and shall, upon written request, be provided with a copy or a summary of their record within a reasonable period of time. The hospice organization or the patient s physician may be forced to refer the patient to another source of care if the client s refusal to comply with the plan of care threatens to compromise the provider s commitment to quality care. PRIVACY - to confidentiality with regard to information about their health, social and financial circumstances, and about what takes place in the home; - to expect the hospice organization to release information only as consistent with its internal policy, required by law or authorized by the client.