This two-page, three-part form is the consent for care or service. It can be used to document if the patient has:
A Legal or Selected Representative
Liability for Payment
Assignment of Benefits
Consolidated Billing - Supplies (for Medicare Home Health patients only)
This form also documents the acknowledgement of information given to the patient for:
Patient s Rights and Responsibilities
Statement of Patient Privacy Rights and Privacy Act Statement - Health Care Records
Basic Home Safety
Agency's Transfer/Discharge Policy
The Admission Service Agreement requires signatures from the patient and/or their legal representative (if any), admitting clinician and the financial guarantor if different from the legal representative. This form works in conjunction with the Welcome to Home Care Services Booklet (Item #3400B).
100 per pack Write Your Own Review
Sign Up For Newsletter
NewsletterDisclaimer : No part of this site constitute medical advice or nor it replaces any advice provided by healthcare adviser. We urge buyer to take advice from the designated healthcare adviser about usage of any product here or if it is suitable for the buyer. This site takes no responsibility of the consequences arising out of the usage of any product from this site. By buying products from this site, buyer agree that buyer has the knowledge of the usage of the product. All warranties implied or explicitly mentioned here are responsibility of the manufacturer of the product. We are not able to accept any insurance or Medicaid or Medical for any purchase. Our apologies for that inconvenience.
WARNING: There are products on this website which can expose you to chemicals known to the State of California to cause cancer and birth defects or other reproductive harm. For more information go to www.p65warnings.ca.gov.
Copyright © 2024 Nimmed. All Rights Reserved.
