1817 Laramie Trail Brooklyn Park, MN Phone: (763) Fax: (763) CLIENT - AGENCY SERVICE AGREEMENT

Transcription

1 1817 Laramie Trail Brooklyn Park, MN Phone: (763) Fax: (763) CLIENT - AGENCY SERVICE AGREEMENT Client Name: Admission Date: Our in-home caregivers are there to assist you and will follow a care plan developed by you, your physician and the RN. Any changes you desire in the care plan must be discussed with the RN and approved by your physician to be sure it is in your best interest. Our caregiver will try to follow your routines and wishes within the limits of the care plan. You need to communicate openly with them so there can be mutual trust and respect If you are scheduled to receive any service (including supervision visits) and are unable to keep the appointment, you need to give notice of cancellation at least four hours in advance of the appointment. Service(s): * Information required by law *SERVICE/DISCIPLINE *FREQUENCY *RATE RN Supervision Visit RN Skilled Visit $ /hr $ /visit LPN $ /hr $ /visit Home Health Aide/PCA $ /hr $ /visit Homemaker $ /hr $ /visit Therapy (list PT, OT, SLP) $ /hr $ /visit Errand Mileage /mile Other (list) Other (list Billing source(s) - check all that apply: Payment Source Box Name/Address/Phone Explain Coverage Insurance Co. Name: Address: Private Pay Phone: Contact Name: Bill to: Name: Address: Phone: Acorn's End Inc. Page 1 of 7

2 Medical Assistance MA #: Authorization Dates: Waiver Programs Indicate Waiver: Authorization Dates: Other (list) Acorn's End Inc. Page 2 of 7

3 Client financially responsible for: Co-payment Deductible Private Pay None If client/family financially responsible, list exactly what responsibility for payment he/she has: You are responsible for payment as noted above. All spenddown amounts, co-payments and deductibles are due immediately upon receipt of bill. Payment plans may be arranged on an individual basis through the agency's administrator. You are responsible for notifying the agency if your payment source changes during the course of your care. *Contingency Action Plan 1. An agency representative will inform you and/or your responsible party as soon as possible, if scheduled services cannot be provided. a. Essential Services: If services are needed for medical or safety reasons and the agency is unable to keep the appointment, the agency will make arrangements acceptable to the client/responsible party to complete services through another reasonable means. These arrangements may include: i. Scheduling clients requiring essential services first, to ensure coverage. ii. Sending a nurse if other service employees are unavailable. iii. iv. Contacting the client's designated family member to provide the service Making arrangements to complete the service through a contract with another compatible provider. b. Non-essential Service: If the agency is unable to keep a scheduled appointment that is not essential for medical or safety reasons, the agency will notify the client or responsible party and make the following arrangements may be included: i. Provide a replacement person ii. Reschedule a new appointment iii. Arrange for other reasonable alternatives. 2. You or your responsible party should contact the agency office or RN on-call regarding a needed change in your scheduled cares. 3. Emergency medical services will be summoned during an emergency unless there is a written physician's order in your record that reflects your wishes consistent with the Adult Health Care Decisions Act and declarations made by you under that act (Advance Directives). If there is a change in your condition and you need to notify the agency, call, and if needed, call 911. Keep a list of emergency numbers by the phone, including ambulance or emergency responder, physician, relatives, neighbors and friends. 4. Please report any problems or dissatisfaction as soon as possible to the agency at. If you wish further discussion, please call the agency Administrator. There is also a formal appeals process which we will be glad to discuss with you. A problem is easier to resolve right after it occurs and before it leads to more misunderstanding. We value our reputation and you, as our best reference. We will make every attempt to promptly resolve your problem. 5. Our agency will enter into a written service agreement with you or your responsible party no later than the second visit. Our agency will not accept new clients unless we have adequate staff, in numbers and qualifications to fulfill the services agreement. (agency) will not discriminate in the provision of its services on any basis prohibited by law. *Information required by law Acorn's End Inc. Page 3 of 7

4 Client Self-Determination Act/Advanced Directive In compliance with the federal and state law (Omnibus Budget Reconciliations Act of 1990 and Minnesota's Adult Health Care Decisions Act), home health care agencies are required to provide you with written information regarding Advance Directives for Health Care. 1. I have been given written materials about my right to accept or refuse medical treatment? 2. I have been informed of my rights to create an Advance Directive. 3. I understand that I am not required to have an Advance Directive in order to receive medical treatment at this agency. 4. I understand that the terms of any Advance Directive that I have executed will be followed by this agency and my caregivers to the extent permitted by law. 5. Do you have an Advance Directive/Living Will? yes (photocopy must be in medical record at the agency) no 6. Do you have a durable power of attorney (DPOA) for heath care? If yes, the following information is needed: Name of DPOA: Address of DPOA: Phone # of DPOA: 7. Do you have a Mental Health Proxy for health care? If yes, the following information is needed: Name of Mental Health Proxy: Address: Phone #: 8. Would you like to be referred to a resource person for further information? yes (name of resource given ) no Agency Responsibilities Send qualified, trained staff. Notify client of any changes in schedule, services or fees. Have an agency representative available by phone at any time services are provided. Respond to client/family concerns. Establish individual plan of care for client. Client Responsibilities Participate in the development of the plan of care. Accept plan of care developed by RN or therapist, client/family, physician. Acorn's End Inc. Page 4 of 7

5 Provide a safe work environment, free of harassment, for agency personnel. Notify office if services need to be cancelled or rescheduled. Pay agreed upon fee for services provided, or make arrange for payment. Contact office immediately with concerns or questions. Acorn's End Inc. Page 5 of 7

6 Agreement for Home Care Services Client Signature Form 1. Terms of Agreement & Medical Consent: The services to be provided to me by the agency have been explained to me. I understand that by signing this agreement, I authorize provision of procedures and/or services to me by Unique Health Care. I understand that my cares are under the direction of my physician and that the agency is not liable for any act or omission when following the instructions of said physician. I also understand a new contract will be negotiated if there is a change in insurance or other 3 rd party payer, or a change in the plan for services. 2. Medical Information Authorization I hereby authorize any holder of medical information (hospital, nursing home, physician's office or other health facility) about me to release to the agency any records pertinent to my medical history, services rendered, or treatment. 3. Permission for Disclosure and Use of Information & HIPAA Notice of Privacy Practices I consent to the release of my agency records to be reviewed by authorized representatives of Medicaid, insurance, and/or any 3 rd party payer for use in determining my home health benefits. I understand that I have the legal right to refuse the release of my personal and medical records now held by the agency and that I am waiving this legal right by signing this consent. This consent shall be valid for whatever period of time is reasonably necessary for the individual/agency requesting to review my clinical records to fulfill the above described purpose(s), or until I revoke this consent in writing. Such a revocation of this consent will have a prospective effect only. I further authorize the agency, Minnesota Department of Health and other licensing bodies to periodically examine my records for the purpose of checking compliance to regulations and requirements. The HIPAA Notice of Privacy Practices has been given and explained to me. Contact information related to reporting privacy concerns has been given and explained to me. 4. Assignment of Benefits I authorize direct payment to the agency of any Medicaid or other 3 rd party benefits otherwise payable to me, for agency-provided products or services. I also authorize any 3 rd party payer to furnish to an agent of our agency any and all information pertaining to any benefits and status of claims submitted by our agency for services rendered. I further authorize the agency to release any and all information pertaining to me for benefit determination. 5. Acknowledge of Financial Responsibility I have read the service agreement outlining my financial responsibilities. I understand and agree to abide by this agreement. 6. Home Care Bill of Rights I have received, read and understand the Home Care Bill of Rights. I understand that the telephone number and address of the Office of Health Facility Complaints is listed on the Home Care Bill of Rights. 7. Advance Directives I have had the opportunity to receive written information and have my questions answered regarding the Advanced Directives/Living Wills for health care. Acorn's End Inc. Page 6 of 7

7 8. OASIS Privacy Rights I have received, read and understand the OASIS statement of Patient Privacy Rights (for Medicare/Medicaid patients) or the Notice about Privacy (for non-medicare/non-medicaid patients). 9. Returned Goods Policy I understand that supplies dispensed to me may not be returned to the agency for credit 10. Plan of Care I have had the opportunity to participate in the plan of care/service. I understand that the plan of care may change and that such changes will be discussed with me. Instructions for care will be explained to me and will become my responsibility in the absence of a home care staff member in my home. 11. Grievance Policy I have been provided with written notice regarding the complaint system which includes my right to complain; name or title of person to contact with complaints; method of submitting a complaint; right to complain to Minnesota Department of Health and Office of Health Facility Complaints; statement that provider will not retaliate because of complaint. I have read this agreement form, understand it, and agree to abide by its terms. I understand that signing this form means the above information has been received and understood by me. Client Signature Date Client Responsible Party (if client unable to sign) Responsible Party's Relationship to Client Agency Representative Signature: Date: Acorn's End Inc. Page 7 of 7