Chse One: PEC PTCC Prvidence Extended Care, and Prvidence Transitinal Care Center, cllectively (d.b.a) Prvidence Anchrage Lng Term Care Services hereinafter referred t as PEC/PTCC/PALTCS respectively., (Resident, Patient and/r designated representative) agree t the fllwing terms, cnditins, and arrangements pertaining t the care f hereinafter referred t as the RESIDENT r PATIENT TERMS OF AGREEMENT This agreement takes effect n This shall terminate upn the discharge f resident/patient, prvided all charges fr services and supplies are paid in full. resident/patient shall have the right t terminate this Admissin Agreement upn thirty (30) days' written ntice, prvided all charges fr services and supplies are paid in full. PAYMENT FOR SERVICES Resident/patient r representative shall be respnsible fr the payment f all charges assessed by Facility fr services and supplies prvided fr the resident/patient within 30 days f receiving the assessed charges. If Resident/patient is nt cvered by r eligible fr Medicare, Medicaid, r the Veterans Administratin, Resident/patient shall pay a rate in accrdance with the current Schedule f Charges. The daily rm rate is $ 832.00 per day (PEC) $1235.00 per day (PTCC) The resident/patient shall be charged fr the day f admissin, but nt fr the day f discharge. Included in this daily rm rate, PALTCS agrees t prvide: Nursing Care Rm and Bard Laundry Service Huse Keeping Services Scial Services Activity Services 1 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s
CHANGES IN CHARGES PALTCS reserves the right t make changes t the rm rate and ancillary charge structure at any time. Any changes t the rm rate will be cmmunicated in writing t the resident/patient r their designated representative 30 days prir t the effective date f such change. ANCILLARY CHARGES In additin t the rm rate, ancillary charges may be incurred. The charges fr these items cannt be established r predicted with certainty. These charges may include: Prescriptin Drugs Medical Supplies In Huse Physician Services Labratry Fees Radilgy Fees Emergency Transprtatin Persnal Services Therapy Services Specialty Beds Wund Vac PAYMENT It is a Resident's/patient s respnsibility t apply fr benefits under the Medicare and/r Medicaid prgrams as sn as resident/patient appears t meet the prgrams' eligibility requirements. Private Pay: The resident/patient r designated representative, n the residents /patients behalf, agrees t pay the daily rm rate in advance f the mnth fr which services are rendered, and the Ancillary Charges rendered in the previus mnth by the 10 th day f each mnth. Cmmercial Insurance: The resident/patient r financially designated representative is respnsible fr verifying Cmmercial Insurance cverage fr SNF (Skilled Nursing Facility) care prir t Admissin. As a curtesy, PALTCS will submit a claim t insurance. It is the respnsibility f the resident/patient r financially designated representative t pay any uncvered balances. Medicaid Cst f Care: Medicaid Cst f Care is determined by the State f Alaska Divisin f Public Assistance, and is payable by the 10 th day f each mnth. If yu are unable t meet this billing date, please cntact PALTCS Business Office t avid further actin. Residents/Patients may chse t have their checks delivered t PEC/PTCC. Resident/patient and financially designated Representative can make direct payments t n site Banker. 2 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s
Medicare: Medicare guarantees nly the first 5 days while an assessment is cmpleted t determine whether the beneficiary meets the specific Medicare criteria enabling cverage beynd the 5 day perid. If Medicare determines that the beneficiary requires skilled nursing r therapy services that meet the needed requirements n a daily basis, Medicare will cver: Days 1 20 cvered at 100% Days 21 100, all csts cvered excluding c-insurance $157.50 per day If Medicare beneficiary des nt meet SNF criteria, beneficiary will receive a decertificatin ntice 2 days prir t Medicare cverage ending. It is imprtant t knw in advance abut alternative payment surces as Medicare beneficiary will be respnsible fr the current daily rate f PEC/PTCC plus any Ancillary charges. When receiving care utside the Facility, resident/patient is respnsible fr ntifying ther healthcare prviders ( Other Prviders ) that resident/patient is receiving services frm a skilled nursing facility under Medicare Part A and prir t receiving such care frm ther prviders said prviders shuld cntact Facility fr apprpriate crdinatin f care/payment. Wrker s Cmpensatin: Wrker s Cmpensatin pays at 100% f allwed charges. Sme carriers have a fee schedule fr therapy services. It is imprtant t btain pre-certificatin frm the apprpriate Wrker s Cmpensatin Case Manager prir t Admissin. Veterans Administratin: If payment is being made by the Veterans Administratin, then rm and bard, nursing services and ancillary services (i.e. physical therapy, pharmacy) are cvered. Other services nt prvided by PALTCS may be cvered but must be preauthrized by the Veterans Administratin. a. VA Eligibility Criteria: Veteran must meet service cnnectin eligibility r Veteran must be at end f life (6 mnths r less) Pharmacy Charges: Residents/patients whse pharmacy charges are paid privately, by cmmercial insurance r a nn-cntracted Medicare Part D plan are required t keep their accunt in gd standing with Prvidence Apthecary. This includes, but is nt limited t ensuring the pharmacy has current and accurate billing infrmatin and making timely payments t Prvidence Apthecary. (See Medicare Part D Cntracted Plans dcument included in this packet) 3 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s
AUTHORIZATION FOR BILLING PALTCS is hereby authrized t furnish and release, in accrdance with facility plicy, such prfessinal and clinical infrmatin as may be necessary fr cmpletin f claims by valid third party agents r agencies frm the medical recrds riginating frm the stay at PALTCS. RESERVATION OF ROOM The resident/patient may request that their rm be held when they are absent frm the facility vernight, fr any reasn. The resident/patient may be charged 85% f the current daily rate f $ 832.00 (PEC) r $ 1235.00 (PTCC) between the 5 th day and the residents return. If the resident/patient is receiving Medicaid, 12 days a year fr therapeutic leaves f absences will be paid. The resident/patient may request that PALTCS hld the rm lnger, but the resident/patient will be respnsible fr 85% f the current daily rate fr PEC r PTCC. Medicare des nt pay fr any bed hld days if a resident/patient is gne frm the facility vernight fr any reasn. The rm may be held accrding t the PALTCS Bed Hld Plicy. Residents/patients may leave the facility t participate in activities withut lsing their Medicare cverage. Medicare Benefit Plicy Manual recgnizes that, althugh mst beneficiaries are unable t leave the facility, an utside pass r shrt leave f absence fr the purpse f attending a special religius service, hliday meal, family ccasin, ging n a car ride, r fr a trial hme visit is nt, by itself evidence that the individual n lnger needs t be in a SNF fr the receipt required skilled care. If a resident/patient decides t take an vernight Leave f Absence, then the resident /patient will be respnsible fr payment, which wuld be ur current daily rate f $ 832.00 (PEC) r $ 1235.00 (PTCC). If a resident/patient is hspitalized 5 days r greater, there will be cntact frm PALTCS t resident/patient r representative t discuss desires t hld r release their bed. If the resident/patient chses nt t hld their bed, they will be readmitted t the next available bed upn readmissin t PALTCS. DESIGNATION The resident/patient designates, a persn ther than the wner and agent r emplyee f the PALTCS, unless such wner, agent r emplyee f the nursing hme is related t the resident, t be his/her representative fr any and all purpses. This representative incurs n financial liability n behalf f the resident/patient. 4 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s
PROTECTED HEALTH INFORMATION/RELEASE OF INFORMATION All Residents/Patients persnal and health infrmatin is cnfidential and will nly be used by individuals invlved with caring fr r cnducting business activities fr ur Residents. Fr examples f hw this infrmatin may be used, and fr PALTCS privacy practices, please see the Jint Ntice f Privacy Practices ntice included in this packet. Additinal cpies are available upn request. PALTCS has the right t btain infrmatin regarding the resident s/patients care frm the resident s/patients physician and ther facilities where the resident/patient has been cared fr. PALTCS has the right t frward such infrmatin as necessary t ther health prfessinals cncerning the resident s/patients cnditin fr medical cnsultatin, transfer t anther health care facility, r when required by law. VALUABLES Residents/patients are asked nt t bring items f high mnetary value t the facility. It is the resident/patient respnsibility t ensure valuables such as laptps/tablets, cash and expensive jewelry are nt left unsecured. A lcked drawer can be made available upn request. The facility safe may be used t lck valuables fr a shrt term basis. Cntact the Banker fr assistance in securing valuables. Reprt lst items by telling any staff member. Lst r damaged persnal items are the respnsibility f the resident/patient except when there is grss negligence n the part f the facility. PHOTO RELEASE Authrizatin fr phts/pictures taken f me as a resident/patient fr the purpse f: Identificatin relating t my care Attached t medical reprts that may be frwarded t ther entities fr the purpse f cntinuity f care, fr payment r ther reasns as authrized As a recrd f my participatin in activities phts may be used fr in-huse displays and this release is gd fr the length f my stay at PALTCS SMOKING PALTCS is an entirely smke-free campus fr Residents/Patients, families, visitrs and staff. This includes the use f any frm f electrnic r e-cigarettes. N smking will be allwed in any area f the interir f the building r n the utside grunds f the facility. Thse wh vilate this plicy will be given a 30 day ntice t discharge frm the facility. Please initial here indicating yu understand ur nn-smking plicy including e- cigarettes. 5 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s
OFF CAMPUS MEDICAL APPOINTMENTS PALTCS will arrange any necessary ff-campus medical appintments fr PALTCS resident/patient. In the event the resident/patient requires an escrt fr any such appintment it is generally expected that the resident/patient r designee prvide a respnsible individual t fulfill this rle. Exceptins wuld include a resident/patient wh wuld require licensed/certified staff t prvide nursing care while the resident/patient is ut fr an appintment. IMMUNIZATIONS Fr the health and well being f all residents, PALTCS immunizes all residents/patients fllwing the Center fr Disease Cntrl (CDC) guidelines with the fllwing vaccines: Influenza, Tetanus/Diphtheria, and Pneumvax. Varicella (Zster) and ther immunizatins are als prvided if clinically indicated. Exceptins t immunizatin include: identified cntra-indicatin, allergy, dcumented prf f current immunizatin status, r resident declines vaccinatin. Immunizatin infrmatin statements frm the CDC are included with this admissin packet. TB SCREENING PALTCS screens regularly fr TB infectin (LTBI) and active TB disease. A screening chest x-ray alng with a TB symptm review is required fr all persns within 60 days prir t admissin. Persns with untreated active TB disease cannt be admitted t a PALTCS facility. Upn admissin, all new residents/patients withut a histry f TB r a prir psitive TST (tuberculin skin test) will receive a TST screen within 72 hurs f admissin. If the first TST is negative, a secnd step TST will be placed in 7 10 days. TB screening will be repeated annually and as needed withut exceptin. An infrmatin dcument frm the CDC regarding TB skin testing is included with this admissin packet. 6 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s
ADMISSION AGREEMENT UNDERSTANDING I hereby acknwledge that I have received the fllwing supprtive dcuments which cntain detailed infrmatin n subjects addressed in this agreement. I further acknwledge that they have als been explained t me rally: Welcme Letter (PTCC) Schedule f Charges Medicare Part D Cntracted Plans Jint Ntice f Privacy Practices (Pamphlet) Immunizatin Infrmatin Statements Resident/Patient Handbk Advance Directives TB Skin Test Infrmatin Statement Privacy Act Statement Authrizatin fr Resident Trust Accunt Rep Payee Cntract The and abve dcuments are hereby understd and meet with the resident s/patients apprval. The resident/patient has read the abve agreement r it has been read t the resident/patient. The resident/patient fully understands and agrees t the abve terms and cnditins. The resident/patient acknwledges receipt f a cpy f this dcument upn it executin. RESIDENT/PATIENT SIGNATURE RESPONSIBLE PARTY DATE DATE 7 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s
RELATIONSHIP PALTCS REPRESENTATIVE DATE DATE 8 P a g e P r v i d e n c e A n c h r a g e L n g T e r m C a r e S e r v i c e s