Please IMMEDIATELY call Good Shepherd Hospice for instructions BEFORE signing any enclosed forms. Monday Friday, 8 a.m. 8 p.

Transcription

1 Please IMMEDIATELY call Good Shepherd Hospice for instructions BEFORE signing any enclosed forms. Monday Friday, 8 a.m. 8 p.m Our specially trained staff will explain each segment form and assist you in accurately completing the forms so that they are acceptable to Medicare, Tricare, Medicaid and other private insurers. These forms must be completed, signed and returned on a priority basis before your requested hospice assessment can be scheduled and before any support or assistance can be delivered. Our staff will provide multiple options for you to conveniently return these forms, including FAX, scan/ , or UPS prepaid overnight Lakeland Hills Blvd., Lakeland, FL Phone Fax POLK HIGHLANDS HARDEE

2 Benefit Eligibility and Verification / Medicare Secondary Payor (This form should only be used by staff who do not have access to the Solutions Form Cabinet and are obtaining consents prior to an Admission assessment. The RN is responsible for entering this information into the Solutions Form at the time of Admission). Patient Elects: Patient Elects (Primary): r Medicare r Medicaid r Private Insurance r VA Benefits r Self Pay Patient Elects (Secondary): r Medicare r Medicaid r Private Insurance r VA Benefits Was AHCA Form signed? r Yes r No If no, did the patient decline to sign? r Yes r No Benefit Eligibility Verification: 1. Have you ever been enrolled in any Hospice Program? r Yes r No 2. Have you filed or plan to file for Social Security Disability or other personal benefits? r Yes r No Medicare/Tricare Secondary Payer (MSP): 1. Is Patient or his/her spouse actively employed? r Yes r No 2. Are services related to an automobile or other accident, including a work-related r Yes r No accident or illness? 3. Is patient entitled to Veterans Administration or Black Lung benefits? r Yes r No If Yes, please specify r Veteran s Administration r Black Lung 4. Is patient entitled to Medicare/Tricare solely as a result of end-stage renal disease? r Yes r No If Yes, date began: BENEFIT ELIGIBILITY AND VERIFICATION / MEDICARE SECONDARY PAYOR GSH413 REV 10/14 PH: Form Completed By: (Print) Team: ID #: Patient Name: (Print) Last First

3 I. CONSENT FOR HOSPICE CARE: I request admission to Good Shepherd Hospice (GSH). I acknowledge I have a terminal condition and understand the focus of GSH is palliative care providing comfort rather than curative. I acknowledge a hospice representative has explained the type of care and services that GSH may provide during the course of my illness. I acknowledge I was given the opportunity to ask questions regarding the types of care and services I may receive, and I understand the information provided to me by GSH. My family, my attending physician (if any), the GSH interdisciplinary group and I will develop my plan of care. I hereby consent to interventions that may be performed as part of my care plan. I have asked family member(s) and significant other(s) to respect the choice of hospice care and to fulfill the role of primary caregiver(s) as able. II. RELATIONSHIP BETWEEN GSH AND PATIENT/FAMILY: I understand: GSH promotes the comfort and dignity of patients and addresses the physical, emotional, social and spiritual needs of the patient and family. GSH services will be provided primarily in my place of residence and/or hospice facility (owned or contracted). If you are currently residing in a facility, hospice staff will coordinate your care with facility staff. Patient care is provided by hospice professionals, students and volunteers, both on a scheduled basis and as needed 24 hours a day, seven days a week. GSH interdisciplinary group does not take the place of my family in caring for me, nor does the GSH medical director or physician designee take the place of my attending physician, if one has been identified. GSH medical director or physician designee provides consultation in pain and symptom management as it relates to my terminal illness as a member of the interdisciplinary group as requested. Clinical notes will be made on care records and care plans concerning the medical, nursing, psychosocial, spiritual and personal information required for hospice to fulfill its duties, and I give my consent and approval for such. GSH pharmacy may select a medication that is generically equivalent to the brand prescribed by my physician. GSH documents containing confidential information about me may be left in my home for continuity of care. I agree that I am responsible for protecting the privacy of such information, and I release GSH, its agents and employees from any and all legal liability that may arise from discussions made by the patient and/or caregivers. III. ACKNOWLEDGEMENT OF RECEIPT OF THE FOLLOWING DOCUMENTS: Notice of Privacy Practices Notice of Rights and Responsibilities Advance Directives Information IV. AUTHORIZATION TO RELEASE PRIVATE HEALTH INFORMATION (PHI): I voluntarily authorize and give my permission and allow disclosure of all my PHI, including information about sensitive conditions (e.g., drug/alcohol/ substance abuse, psychological/psychiatric/mental impairments, developmental disabilities, sickle cell anemia, HIV/AIDS or other communicable or sexually transmitted diseases and genetic diseases), if any, to and from GSH and any of the following: (1) my insurance company or any authority or organization, private or governmental, including, but not limited to, the Social Security Administration and its intermediary, Medicare/Tricare and Medicaid, which may be responsible for reimbursement or payment for the care and services provided; and (2) other healthcare providers involved in my medical care (including their staff members, agents and business associates) for continuity and coordination of care purposes, as permitted by law. This includes information in paper or oral form and records created before or after the date of my signature below. This authorization will remain in effect until the day I withdraw my permission. V. ELECTION OF HOSPICE MEDICARE/TRICARE: I elect the Medicare/Tricare Hospice Benefit provided by GSH, and I acknowledge, consent and agree to the following: The patient, family, attending physician and the GSH interdisciplinary group collaborate together to develop an individualized plan of care for the patient/family and determine the appropriate levels of care needed. I will work with GSH and my attending physician to make all necessary arrangements for care related to my terminal diagnosis for which GSH is treating me. GSH will pay for care related to my terminal diagnosis, as deemed reasonable and medically necessary. The approximate cost and methods of reimbursement through Medicare/Tricare for hospice care has been explained to me. I understand Medicare/Tricare will be billed directly for the cost of my hospice care whether provided within the home, hospital, assisted living facility, nursing home or hospice facility (owned or contracted). For the duration of my election to receive hospice care, I waive all rights to Medicare/Tricare payments: (i) for hospice care other than the care provided by GSH, unless such care is provided under an arrangement made by GSH and (ii) any Medicare/Tricare services that are related to the treatment of my terminal condition for which hospice was elected, or a related condition, except for services provided by GSH or another hospice under an arrangement with GSH, or my attending physician, if my attending physician is not an employee of GSH or does not receive compensation from GSH for such services. The care provided by my attending physician can be billed to Medicare Part B. Nursing home room and board is NOT a hospice Medicare/Tricare-approved benefit, other than respite care. Should I secure care considered curative outside of the hospice plan of care and without the involvement of GSH, I understand I may be financially responsible. I understand I may revoke this hospice benefit election, in writing, and be discharged from GSH at any time with my original Medicare/Tricare benefits fully restored. Care for all illnesses other than my primary terminal diagnosis for which hospice is treating me can be billed to Medicare/Tricare in the traditional manner. PATIENT AGREEMENT AND INFORMED CONSENT FOR CARE PG 1 GSH337 REV 09/14 PH:

4 VI. ELECTION OF HOSPICE MEDICAID: (Separate form required.) I elect the Medicaid Hospice Benefit provided by GSH, and I acknowledge, consent and agree to the following: The patient, family, attending physician and the GSH interdisciplinary group collaborate together to develop an individualized plan of care for the patient/family and determine the appropriate levels of care needed. I will work with GSH and my attending physician to make all necessary arrangements for care related to my terminal diagnosis for which GSH is treating me. GSH will pay for care related to my terminal diagnosis, as deemed reasonable and medically necessary. The approximate cost and methods of reimbursement through Medicaid for hospice care has been explained to me. I understand Medicaid will be billed directly for the cost of my hospice care whether provided within the home, hospital, assisted living facility, nursing home or hospice facility (owned or contracted). For the duration of my election to receive hospice care, I waive all rights to Medicaid payments: (i) for hospice care other than the care provided by GSH, unless such care is provided under an arrangement made by GSH and (ii) any Medicaid services that are related to the treatment of my terminal condition for which hospice was elected, or a related condition, except for services provided by GSH or another hospice under an arrangement with GSH, or my attending physician, if my attending physician is not an employee of GSH or does not receive compensation form GSH for such services. The care provided by my attending physician can be billed to Medicaid. Should I secure care considered curative outside of the hospice plan of care and without the involvement of GSH, I understand I may be financially responsible. I understand I may revoke this hospice benefit election, in writing, and be discharged from GSH at any time with my original Medicaid benefits fully restored. Care for all illnesses other than my primary terminal diagnosis for which hospice is treating me can be billed to Medicaid in the traditional manner. VII. ELECTION OF INSURANCE HOSPICE BENEFIT: I elect insurance benefits for hospice care provided by GSH, and I acknowledge, consent and agree to the following: The approximate cost and methods of reimbursement for hospice care have been explained to me. I understand the decision of GSH to accept me into care will not be based upon my ability or inability to pay and the GSH services will not be adjusted based upon any change in my ability to pay. I authorize payment of benefits from any third-party payor directly to GSH for services rendered. GSH will bill my third-party payor as a courtesy to me. I understand I am responsible for all deductibles, co-payments and any cost of services over my insurance benefit limits, based on my ability to pay. VIII. NO COVERAGE: I understand that GSH will assist me with exploring my eligibility for other third party benefits, including Community Care. I agree I am financially responsible for any charges not covered by a third party and will work out a payment plan based upon my ability to pay. IX. DESIGNATION OF ATTENDING PHYSICIAN: I understand I must identify an attending physician to provide my hospice care. An attending physician is the person who has the most significant role in the determination and delivery of my medical care. I understand I have the right to keep my community physician/advanced Registered Nurse Practitioner (ARNP) or I may choose Good Shepherd Hospice Medical Services. Good Shepherd Hospice Medical Services may provide an ARNP, a Doctor of Medicine (MD) or a Doctor of Osteopathy (DO) to serve as my attending physician. All hospice care will be directed through my attending physician and the other hospice team members. I understand I have the right to change my attending physician at any time while under the care of hospice., is my choice of attending for hospice care. (print full name of attending physician) The physician/arnp will be contacted to accept the role as attending. Patient elects: r Hospice Medicare/Tricare r Hospice Medicaid (separate form req.) r Private Insurance r VA Benefits I attest the foregoing statements have been read and understood. Patient Signature: Date: / / Patient unable to sign because: Authorized Representative Signature (if any): Date: / / Authorized Representative: Relationship to Patient: (print name) Address: Phone: Representative is acting on patient s behalf as: r Parent (if minor) r Guardian r HCS r DPOA-HC r HC Proxy Hospice Representative Signature: Date: / / PATIENT AGREEMENT AND INFORMED CONSENT FOR CARE PG 2 GSH337 REV 09/14 PH: Effective Date: Team: ID #: Patient Name: (Print) Last First WHITE: Medical Records YELLOW: Patient/Family PINK: Facility

5 FLORIDA MEDICAID HOSPICE CARE SERVICES Election Statement The Florida Medicaid Hospice Care Services program has been explained to me. I have been given the opportunity to discuss the benefits, requirements and limitations of this program and the terms of the election statement. I understand that I will be entitled to elect Medicaid hospice care coverage as long as I am Medicaid eligible and I am certified by the hospice physician as being terminally ill. I understand that by signing the election statement, I am waiving all rights to Medicaid services for the duration of the election of hospice care for the following services: Hospice care provided by a hospice other than the hospice designated by me (unless provided under arrangements made by the designated hospice); and Any Medicaid services that are related to the treatment of the condition, or a related condition, for which hospice care was elected, or that are equivalent to hospice care with the following exception: services provided by my attending physician (if that physician is not employed by the designated hospice or receiving compensation from the hospice for those services). I understand that I may revoke the hospice benefit at any time by signing a statement to that effect, specifying the date when the revocation is to be effective and submitting the statement to the hospice prior to that date. At that time, I understand my rights to other Medicaid services will resume, provided I continue to be Medicaid eligible. By signing this statement, I am electing the following hospice to provide me with the services of the Medicaid hospice care program: NAME OF HOSPICE Signature of Participant or Representative Election Date Signature of Hospice Representative Date AHCA , July 1999 (59G-4.140, F.A.C.) Distribution of Copies: 1. Coordinator (DCF) 2. Physician 3. Hospice 4. Area Medicaid Office 5. HMO (if applicable)

6 Good Shepherd Hospice Optional Forms

7 I understand that my Attending Physician is (print patient or representative name) the health care practitioner who has the most significant role in the determination and delivery of my medical care. I also understand that my Attending Physician can be either a doctor of medicine (MD), a doctor of osteopathy (DO) or an Advanced Registered Nurse Practitioner (ARNP), and that I may choose my Attending Physician from the community or from Good Shepherd Hospice Medical Services. Good Shepherd Hospice Medical Services is a physician group, associated with Good Shepherd Hospice, which employs and contracts with physicians and employs ARNPs with palliative care experience. Although I was required to identify who my Attending Physician was at the time I elected hospice care, I understand that I have the right to change my choice of Attending Physician at any time, and as many times as I desire, while under the care of Good Shepherd Hospice. I now wish to change my choice of Attending Physician. Effective / /, I choose (print full name of attending physician) as my new Attending Physician for the following reason(s) (choose all that apply): r My current designated Attending Physician is no longer able, available or willing to fulfill the responsibilities as my Attending Physician, while I am receiving hospice care. r I am dissatisfied with my current designated Attending Physician. r Due to a change in my circumstances, the new Attending Physician identified above will be better able to coordinate my care and act as my Attending Physician, while I am receiving hospice care. r Other: The physician/arnp I identified above as my new Attending Physician has been contacted and has accepted this role as Attending Physician as of the effective date indicated above. I understand that the effective date of this change cannot be earlier then the date I signed this attestation. I have discussed this change of Attending Physician with hospice staff and have had all my questions answered to my satisfaction. I ACKNOWLEDGE THAT THIS CHANGE IN MY CHOICE OF ATTENDING PHYSICIAN WAS MADE VOLUNTARILY AND OF MY OWN FREE WILL. Patient/Legal Representative Signature Date / / Patient/Legal Representative Name (please print) Reason Patient Did Not Sign ATTESTATION CHANGE OF CHOICE OF ATTENDING PHYSICIAN FOR HOSPICE CARE GSH392 REV 11/14 PH: Team: ID #: Patient Name: (Print) Last First WHITE: Medical Records YELLOW: Patient/Representative

8 I agree with my transfer or admission to a Good Shepherd Hospice hospice house for general inpatient care, which is a level of skilled care used on a short-term basis for pain control, symptom management or skilled nursing needs that cannot otherwise be provided in my residence. In connection with my transfer/admission to the hospice house, my understanding is as follows: A plan for my discharge from the hospice house will be discussed with me at the time of admission. When my symptoms are controlled and a level of stability is achieved, I will be discharged and expected to return to my primary residence. If, upon discharge, my primary residence is not adequate to safely meet my care needs, I will consider alternative placement choices. If nursing home placement is my chosen long-term care option, I may be required to accept placement in a nursing home that was not my first choice, due to availability. If I refuse to return to my primary residence or an alternative setting when my discharge is appropriate, I will be charged for non-covered general inpatient services rendered at the current Good Shepherd Hospice rate of $ / day. Services in the hospice house include: medical care, nursing care, assistance with personal care, counseling, spiritual care, volunteer services, medical equipment, dietary requirements, medical supplies and housekeeping. Services are provided 24 hours a day, seven days a week. If a do not resuscitate order (DNRO) has not been initiated, in the event I experience a cardiac arrest while in the hospice house, cardiopulmonary resuscitation (CPR) will be performed, 911 will be called, and I will be transferred to the nearest hospital. Visiting hours are unlimited, but between the hours of 10:00 p.m. through 7:00 a.m., only two (2) visitors are allowed at a time. If at any time visitors become disruptive, they will be asked to leave. Children are permitted to visit, but must be supervised by an adult at all times. Children are expected to visit for a duration of time appropriate for their age. Patients and visitors may smoke in designated smoking areas only. Lighters or matches are not allowed in patient rooms at any time and must be checked into the nurse s station. Good Shepherd Hospice is not responsible for any personal valuables I may take with me into the hospice house. Personal belongings must be picked up, or arrangements made to do so by an authorized person, within ten (10) days of discharge from the house. Good Shepherd Hospice reserves the right to dispose of any of my unclaimed property left in the hospice house in accordance with applicable law. Visiting pets are welcome, but must have current vaccinations and either be leashed or caged at all times. Good Shepherd Hospice staff may request that you provide proof of current vaccinations. Weapons, illegal drugs, intoxicants, and disruptive behavior are prohibited at the hospice house. My failure to comply with this requirement will result in immediate discharge from the hospice house. In the event any person visiting me fails to comply with this requirement, such visitor may be removed from the hospice house and may be prevented from re-entering. I attest I have read, understand, and agree to the foregoing statements. Patient/Legal Representative Signature / / Date Legal Representative Name (please print) Hospice Representative Signature Reason Patient Did Not Sign / / Date HOSPICE HOUSE EXPLANATION AND EXPECTATIONS GSHH005 REV 02/14 PH: ID #: Patient Name: (Print) Last First WHITE: Medical Records YELLOW: Patient/Representative

9 State of Florida DO NOT RESUSCITATE ORDER (please use ink) Patient s Full Legal Name: (Print or Type Name) Date: PATIENT S STATEMENT Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): q Surrogate q Proxy (both as defined in Chapter 765, F.S.) q Court appointed guardian q Durable power of attorney (pursuant to Chapter 709, F.S.) (Applicable Signature) (Print or Type Name) PHYSICIAN S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient s cardiac or respiratory arrest. ( _ ) _ - (Signature of Physician) (Date) Telephone Number (Emergency) (Print or Type Name) (Physician s Medical License Number) DH Form 1896, Revised December 2004 PHYSICIAN S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the vent of the patient s cardiac or respiratory arrest. ( _ ) _ - (Signature of Physician) (Date) Telephone Number (Emergency) Patient s Full Legal Name (Print or Type) State of Florida DO NOT RESUSCITATE ORDER (Date) PATIENT S STATEMENT Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): q q q q Surrogate Proxy (both as defined in Chapter 765, F.S.) Court appointed guardian Durable power of attorney (pursuant to Chapter 709, F.S.) (Print or Type Name) (Physician s Medical License Number) (Applicable Signature) (Print or Type Name) DH Form 1896,Revised December 2004

10 Estado de Florida ORDEN DE NO RESUCITAR (por favor, use tinta) Este lado del formulario está destinado únicamente a la traducción. Los proveedores de Servicios Médicos de Emergencia y el personal médico sólo deben acatar la versión en inglés del presente formulario. División de Operaciones Médicas de Emergencia, Oficina de Traumatología Nombre legal completo del paciente: Fecha: (Escriba el nombre con letra de imprenta o digítelo) DECLARACIÓN DEL PACIENTE Sobre la base del consentimiento informado, yo, quien suscribe, por medio de la presente ordeno que no se me proporcione RCP. (Si este documento no está firmado por el paciente, marque la casilla pertinente): q Responsable del sujeto q Apoderado (ambos, según se definen en el Capítulo 765 de los Estatutos de Florida) q Tutor designado por el tribunal q Poder de duración indeterminada para fines de atención médica (de acuerdo con el Capítulo 709 de los Estatutos de Florida) (Firma correspondiente) (Escriba el nombre con letra de imprenta o digítelo) DECLARACIÓN DEL MÉDICO Yo, quien suscribe, un médico licenciado de acuerdo con el Capítulo 458 ó 459 de los Estatutos de Florida, soy el médico del paciente anteriormente mencionado. Por medio de la presente, ordeno que no se proporcione resucitación cardiopulmonar (ventilación artificial, compresión torácica, intubación endotraqueal y desfibrilación) al paciente en caso de que éste sufra un paro cardíaco o respiratorio. ( _ ) _ - (Firma del médico) (Fecha) Número telefónico (Emergencia) (Escriba el nombre con letra de imprenta o digítelo) (Número de licencia médica) FORMULARIO 1896 DEL DEP. DE SALUD, revisado en diciembre de 2004 DECLARACIÓN DEL MÉDICO Yo, quien suscribe, un médico licenciado de acuerdo con el Capítulo 458 ó 459 de los Estatutos de Florida, soy el médico del paciente anteriormente mencionado. Por medio de la presente, ordeno que no se proporcione resucitación cardiopulmonar (ventilación artificial, compresión torácica, intubación endotraqueal y desfibrilación) al paciente en caso de que éste sufra un paro cardíaco o respiratorio. ( _ ) _ - (Firma del médico) (Fecha) Número telefónico (Emergencia) (Escriba el nombre con letra de imprenta o digítelo) (Número de licencia médica) Estado de Florida ORDEN DE NO RESUCITAR Nombre legal completo del paciente (Fecha) (Escriba con letra de imprenta o digítelo) DECLARACIÓN DEL PACIENTE Sobre la base del consentimiento informado, yo, quien suscribe, por medio de la presente ordeno que no se me proporcione RCP. (Si este documento no está firmado por el paciente, marque la casilla pertinente): q q q q Responsable del sujeto Apoderado (ambos, según se definen en el Capítulo 765 de los Estatutos de Florida) Tutor designado por el tribunal Poder de duración indeterminada para fines de atención médica (de acuerdo con el Capítulo 709 de los Estatutos de Florida) FORMULARIO 1896 DEL DEP. DE SALUD, revisado en diciembre de 2004 (Firma correspondiente) (Escriba el nombre con letra de imprenta o digítelo) Non Legal Konplè pasyan an: Eta Laflorid LÒD PA RESISITE (tanpri itilize lank) Kote fòm sa a se pou tradiksyon sèlman. Founisè Sèvis Medikal Dijans ak fonksyonè medikal dwe onore vèzyon Anglè fòm sa a. Divizyon Pou Operasyon Medikal Dijans, Biwo Twoma (Ekri an Majiskil oswa Tape Non an) DEKLARASYON PASYAN AN Baze sou konsantman enfòme an, mwen, ki siyen la, ak prezant sa a deklare pou yo pa fè CPR sou mwen ditou. (Si pasyan an pat siyen limenm, tcheke kazye ki apwopriye an): q Reprezantan Swen Sante q Pwokirè (tou de jan li dekri nan Chapit 765, F.S.) q Gadyen Tribinal la Chwazi q Responsablite Pwokirasyon Dirab (daprè Chapit 709, F.S.) Dat: (Siyati ki Aplikab) (Ekri an Majiskil oswa Tape Non an) DEKLARASYON DOKTÈ AN Mwen, ki siyen la a, yon doktè sètifye daprè Chapit 458 oswa 459, F.S., mwen doktè pasyan an ki nonmen anwo la. Mwen dirije pou yo kenbe ak elimine resisitasyon kadyopilmonè (vantilasyon atifisyèl, konpresyon kadyak, endotrakyal entibasyon akdefibrilasyon) pou pasyan an Sizoka pasyan an ta gen yon epizòd arèdkè oswa respiratwa. ( _ ) _ - (Siyati Doktè an) (Dat) Nimewo Telefòn (Ijans) (Ekri an Non an Majiskil) (Nimewo Lisans Medikal Doktè an) Fòm 1896 DH, Revize Desanm 2004 DEKLARASYON DOKTÈ AN Mwen, ki siyen la a, yon doktè sètifye daprè Chapit 458 oswa 459, F.S., mwen doktè pasyan an ki nonmen anwo la. Mwen dirije pou yo kenbe ak elimine resisitasyon kadyopilmonè (vantilasyon atifisyèl, konpresyon kadyak, endotrakyal entibasyon akdefibrilasyon) pou pasyan an sizoka pasyan an ta gen yon epizòd arèdkè oswa respiratwa. ( _ ) _ - (Siyati Doktè an) (Dat) Nimewo Telefòn (Ijans) (Ekri an Majiskil oswa Tape Non an) (Nimewo Lisans Medikal Doktè an) Eta Laflorid LÒD PA RESISITE Non Legal Konplè pasyan an (Ekri an Majiskil oswa Tape) (Dat) DEKLARASYON PASYAN AN Baze sou enfòmasyon konsanti, mwen, ki siyen la, ak prezant sa a dirije pou yo pa fè CPR oswa elimine. (Si pasyan an pat siyen limenm, tcheke kazye ki apwopriye an): q Reprezantan Swen Sante q Pwokirè (tou de fason ki dekri nan Chapit 765, F.S.) q Gadyen Tribinal la Chwazi q Responsablite Pwokirasyon Dirab (daprè Chapit 709, F.S.) Fòm 1896 DH, Revize Desanm 2004 (Siyati ki Aplikab) (Ekri an Majiskil oswa Tape Non an)

11 Good Shepherd Hospice General Information

12 Notice of Privacy Practices EFFECTIVE MAY 6, 2015 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. At Chapters Health System, Inc. ( Chapters Health System ), we understand that medical information about you and your health is personal, which is why we are committed to maintaining the privacy of such information. Each time you are visited or treated by a health care provider or entity that is part of Chapters Health System, a record of the care and services you receive is created. In addition, during the course of your care and treatment health care providers and entities in Chapters Health System may receive records from other healthcare providers and entities involved in your care and treatment. These records created or received during the course of your care will include protected health information about you. (Please see the definition of protected health information in Section I, below.) This Notice of Privacy Practices ( Notice ) explains the ways in which your protected health information may be used or disclosed. In addition, this Notice will describe your rights and Chapters Health System s obligations regarding the use and disclosure of your protected health information. It is important that you read and understand this Notice before signing any acknowledgment of receipt of such Notice. If you have any questions regarding the information contained in this Notice, wish to exercise your rights as explained in this Notice, or would like further information concerning your privacy rights, please contact the Privacy Officer for Chapters Health System at: Chapters Health System, Inc Telecom Drive, Suite 300 West Temple Terrace, Florida (813)

13 Designation as a Single Covered Entity For purposes of this Notice, and for all purposes permitted under the Health Insurance Portability and Accountability Act of 1996 (the Act ) and the rules promulgated thererunder, as such rules may be amended or supplemented from time to time (collectively with the Act, HIPAA ), the following covered entities that are affiliated with Chapters Health System have designated themselves as a single covered entity effective as of May 6, 2015: LifePath Hospice 3010 West Azeele Street Tampa, Florida HPH Hospice Majestic Boulevard Hudson, Florida Chapters Health Palliative Care Telecom Drive, Suite 300 West Temple Terrace, Florida Good Shepherd Hospice 320 West Main Street Lakeland, Florida HPH Home Health Majestic Boulevard, Suite 1 Hudson, Florida Chapters Health Pharmacy 111 Kelsey Lane, Suite F Tampa, Florida Throughout this Notice, the single covered entity comprised of the above companies is referred to as Chapters. This designation may be amended from time-to-time to add new covered entities that are under the common control and ownership of Chapters Health System, Inc. I. What is Protected Health Information or PHI? Certain sections of HIPAA, in particular 45 C.F.R. Part 160 and Subparts A and E of Part 164 (the Privacy Rule ), protect all individually identifiable health information. Your individually identifiable health information is information that (1) relates to your mental health or condition, the provision of your health care, or the payment for your health care, and (2) either identifies or could be used to identify you. When your individually identifiable health information is maintained by a health care provider or entity subject to HIPAA, such as Chapters, the information is considered protected health information. This is true regardless of whether the information is transmitted or maintained in electronic, paper, or oral form. Many common identifiers you provide to Chapters, such as your name, address, date of birth, and Social Security number, are considered protected health information. In addition, your protected health information may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity and similar types of health-related information. Throughout this Notice, protected health information may be abbreviated as PHI.

14 II. Permitted Uses and Disclosures of PHI The following categories describe ways Chapters may use and disclose your PHI. Not every use or disclosure in a category will be listed; however, all of the ways Chapters is permitted to use and disclose PHI information will fall within one of the categories. Treatment, Payment, Health Care Operations and Fund Raising Treatment Chapters may use or disclose your PHI to provide you with medical treatment or services. In addition, Chapters may disclose information about you to doctors, nurses, medical students or other personnel who are involved in your care and treatment. For example, when personnel from Chapters provide care, treatment, or other services to you, information regarding your condition and the care, treatment, or services provided will be documented. This information will be shared among your health care providers to make decisions about your course of treatment or, if applicable, your hospice plan of care. Payment Chapters may use or disclose your PHI so that the services you receive may be billed and payment collected from you, an insurance company or third party payor. For example, Chapters may send a bill to Medicare, Medicaid, or your private insurer for payment of the care, treatment, or services that Chapters provides to you. The bill may contain information that identifies you, your diagnosis, and procedures, and supplies used. Chapters may also provide your PHI to our business associates, such as billing companies, claims processing companies, and others that process health care claims on behalf of Chapters. Health Care Operations Chapters may use or disclose your PHI in connection with the health care operations of Chapters. Health care operations include quality assessment activities, reviewing the competence or qualifications of health care professionals, evaluating provider performance, and other business operations. For example, Chapters may use your health information to provide data for performance improvement activities or outcome studies. Chapters may also provide your PHI to its accountants, attorneys, auditors, consultants, and others to make sure Chapters complies with the various laws governing Chapters. Fund Raising Chapters may use or disclose your PHI to its business associates or its related foundation in an effort to raise money for Chapters and its operations. The information Chapters releases will be limited to your contact information (such as your name, address and telephone number), the dates you received treatment or services, and the Chapters program providing such treatment or services. If you request that your information not be used or disclosed for fundraising purposes, Chapters will take steps to comply with your request. A description of how you can opt out of receiving any fundraising communications will be included with any fundraising materials you receive from Chapters. Other Situations Appointment Reminders Chapters may use or disclose your PHI to remind you that you have an appointment at a Chapters facility or with a Chapters provider.

15 As Required by Law Chapters may disclose your PHI for law enforcement purposes and as required by state or federal law. For example, certain laws may require Chapters to report instances of abuse, neglect, or domestic violence; to report certain types of injuries (such as gunshot wounds); or to assist law enforcement in locating a suspect, fugitive, material witness or missing person. Chapters will inform you or your representative if it discloses your PHI because it believes you are a victim of abuse, neglect or domestic violence, unless it determines that notifying you or your representative would place you at risk. In addition, Chapters must provide PHI to comply with an order in a legal or administrative proceeding. Finally, Chapters may be required to disclose your PHI in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made, by us or the requesting party, to contact you about the request or to obtain an order to protect the requested PHI. Business Associates There may be some services provided by business associates of Chapters, such as a billing, legal, or consulting services. Chapters may disclose your PHI to our business associates so that they can perform the job Chapters has asked them to do. To protect your PHI, Chapters requires its business associates to enter into a written contract that requires them to appropriately safeguard your PHI. Coroners, Medical Examiners, Funeral Directors Chapters may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Chapters may also release your PHI to funeral directors as necessary to carry out their duties. Disaster Relief Chapters may disclose your PHI to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. Disclosure of Information that is Not Individually Identifiable Any documentation or information that (a) does not personally identify you and (b) cannot be used to personally identify you, does not constitute PHI. Chapters may use or disclose such documentation or information as required or permitted by applicable law. Emergencies Chapters may use or disclose your PHI if you need emergency treatment or if it are required by law to treat you but is unable to obtain your consent. In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), personnel of Chapters may, using their professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, Chapters will disclose only the PHI relevant to the person s involvement in your care and will try to obtain your consent as soon as it reasonably can after treating you. Health Oversight Chapters may disclose your PHI to a health oversight agency for activities authorized by law. These activities include audits; civil, administrative, or criminal investigations or proceedings; inspections; licensure or disciplinary actions; or other activities necessary for oversight of the health care system, government programs, and compliance with civil rights laws. Individuals Involved in Your Care or Payment for Your Care Chapters may disclose your PHI to your family members or friends involved in your care or the payment for your care if you verbally agree to do so or if you are given an opportunity to object to such a disclosure and you do not raise an

16 objection. Chapters may also disclose PHI to your family or friends if it can infer from the circumstances, based on our professional judgment that you would not object. For example, Chapters may assume you agree to our disclosure of your PHI to your spouse when you bring your spouse with you to an appointment when treatment or while treatment is discussed. Chapters personnel may also use their professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or X-rays. Survivors of our hospice patients may elect to receive bereavement services provided by a counselor; in the course of providing such services, Chapters may disclose your PHI. Military and Veterans If you are a member of the armed forces, Chapters may release medical information about you as required by military command authorities under certain circumstances. Chapters may also release medical information about foreign military personnel to the appropriate foreign military authority. National Security and Intelligence Activities Chapters may disclose PHI to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by law. Organ and Tissue Donation If you are an organ, tissue, or eye donor (or if you have not indicated that you do not wish to be such a donor), Chapters may release your PHI to organizations that handle organ procurement or organ, tissue, or eye transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation. Protective Services for the President and Others Chapters may disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. Provider Directory Unless you object, Chapters may include limited information about you in its provider directory while you are a patient, including your name, location (if in a Chapters facility), your general condition (e.g. fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your information and religious affiliation may also be given to a member of the clergy, even if the clergy member does not ask for you by name. Public Health Chapters may disclose your PHI to a public health authority that is authorized by law to collect or receive such information, such as for the purpose of preventing or controlling disease, injury or disability; reporting births, deaths or other vital statistics; reporting child abuse or neglect; notifying individuals of recalls of products they may be using; notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition. Research Under certain circumstances, Chapters may use or disclose your PHI for research purposes, but only if the use and disclosure of your PHI has been reviewed and approved by a special privacy board or institutional review board, if you provide a written authorization, or if such disclosure is made in accordance with section , Florida Statutes, and other applicable laws and regulation.

17 To Avert a Serious Threat to Health or Safety Chapters may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Such use or disclosure would be to someone able to help prevent the threat. Treatment Alternatives and Other Health-Related Benefits and Services Chapters may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives and to tell you about health related benefits, services or medical education classes that may be of interest to you. Workers Compensation Chapters may use or disclose your PHI as permitted by laws relating to workers compensation or related programs. III. Uses and Disclosures Requiring Written Authorization Except as described in this Notice, or as otherwise permitted by law, Chapters will not use or disclose your PHI without your written authorization. Your written authorization will specify particular the uses or disclosures that you choose to allow. If you do authorize us to use or disclose your PHI for reasons other than treatment, payment or health care operations, you may revoke your authorization in writing at any time by contacting the Privacy Officer for Chapters (see page one of this Notice). If you revoke your authorization in writing, Chapters will no longer use or disclose your PHI for the purposes covered by the authorization, except where it has already relied on the authorization. Examples of uses and disclosures requiring you written authorization include the following: Psychotherapy Notes A signed authorization (or court order) is required for any use or disclosure of psychotherapy notes except to carry out certain treatment, payment or health care operations and for use by Chapters for treatment, for training programs or for defense in a legal action. Marketing A signed authorization is required for the use or disclosure of your PHI for a purpose that encourages you to purchase or use a product or service except for certain limited circumstances. This does not include face-to-face communications with you concerning products or services that may be of benefit to you and about prescriptions you have already been prescribed. Sale of Protected Health Information A signed authorization is required for the use or disclosure of your PHI in the event that Chapters receives remuneration for such use or disclosure, except under certain circumstances as allowed by federal or State law. IV. Your Rights Concerning PHI Although your health records are the physical property of Chapters, you have certain rights with regard to the information Chapters maintains about you. You have the right to: Receive a Paper Copy of this Notice You have the right to receive a paper copy of this Notice upon request.

18 Access, Inspect, and Copy PHI You have the right to access, inspect, and copy your PHI for as long as Chapters maintains your medical record. In order to exercise such right, you must make a written request for access to the Privacy Officer at the address listed on the first page of this Notice. Chapters may charge you a reasonable fee for the processing of your request and the copying of your medical record pursuant to applicable state law. In certain circumstances, Chapters may deny your request to access your PHI, and you may request that Chapters reconsider its denial. Depending on the reason for the denial, another licensed health care professional chosen by Chapters may review your request and the denial. Request Restrictions You have the right to request a restriction or limitation on the use or disclosure of your PHI for the purpose of treatment, payment or health care operations, except for in the case of an emergency. In order to exercise such right, you must make a written request for a restriction to the Privacy Officer at the address listed on the first page of this Notice. You also have the right to request a restriction on the information Chapters discloses to a family member or friend who is involved with your care or the payment of your care. Please note that, in certain circumstances, Chapters is not legally required to agree to your request for a restriction. Chapters will always notify you in writing of its decision regarding your restriction requests. Restrict Disclosure for Services Paid by You in Full You have the right to restrict the disclosure of your PHI to a health plan if the PHI pertains to health care services for which you paid in full directly to Chapters. Request Amendment You have the right to request that Chapters amend your PHI if you believe it is incorrect or incomplete, for as long as Chapters maintains your medical record. In order to exercise such right, you must make a written request for amendment to the Privacy Officer at the address listed on the first page of this Notice. Your request should include detailed information and documentation supporting your request. Please note that Chapters may deny your request to amend if (a) Chapters did not create the PHI at issue, (b) your request pertains to information that Chapters does not maintain, (c) your request pertains to information that you are not permitted to inspect or copy (such as psychotherapy notes), or (d) Chapters determines that the PHI is accurate and complete. Accounting of Disclosures You have the right to request an accounting of disclosures of your PHI made by Chapters (or by other persons or entities on behalf of Chapters) during the six (6) years prior to the date of your request. Such right does not apply to disclosures made for treatment, payment or health care operations purposes or for other types of disclosures specifically exempted by law. In order to exercise such right, you must make a written request for an accounting to Privacy Officer at the address listed on the first page of this Notice. Your written request should indicate in what form you want the accounting (for example, on paper or electronically, if available) and the specific time period for which you are requesting the accounting. The first accounting you request within a twelve (12) month period will be complimentary. For additional accountings, Chapters may charge you for the costs of providing the accounting. Chapters will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

19 Confidential Communications You have the right to request that Chapters communicate with you about your PHI by certain means or at certain locations. For example, you may specify that Chapters call you only at your home phone number. In order to exercise such right, you must make a written request to the Privacy Officer at the address listed on the first page of this Notice. Your request must specify how and where Chapters may contact you. Notice of a Breach You have the right to be notified if Chapters or one of its business associates become aware of a breach of your unsecured PHI. V. Chapters Duties and Rights Concerning PHI Chapters is required by law to maintain the privacy of your PHI, to provide you with notice of its legal duties and privacy practices with respect to PHI, and to notify you following a breach of unsecured PHI. In so doing, Chapters is required to abide by the terms of the Notice of Privacy Practices currently in effect. As noted in the section pertaining to your rights, you are entitled to a copy of the Notice of Privacy Practices currently in effect. Chapters reserves the right to change the terms of this Notice at any time and to make the new provisions effective for all PHI maintained by Chapters. If and when this Notice is revised, Chapters will notify you by posting a copy on our website at In addition, Chapters will post the current Notice at our location(s) with its effective date identified on the first page of the Notice. You may request and obtain a copy of the current Notice at any time by contacting the Privacy Officer of Chapters Health System at the address and telephone number provided on the first page of this Notice. VI. Filing a Complaint If you believe your privacy rights have been violated, you may file a complaint with Chapters or the Secretary of the Department of Health and Human Services, Atlanta, GA. For addition al information concerning how to file a complaint with HHS, please see the following webpage: To file a complaint with Chapters, please contact the Privacy Officer or Corporate Compliance Officer for Chapters Health System at: Chapters Health System, Inc Telecom Drive, Suite 300 West Temple Terrace, Florida (813) Chapters supports your right to the privacy of your PHI and will not retaliate in any way if you chose to file a complaint.

20 Good Shepherd Hospice Resource Manual and Care Guide The Good Shepherd Hospice Program 1: General Information The information in this book is designed to assist you while you are in the Good Shepherd Hospice program, and provide specific information on hospice patient care. About Hospice Hospice is a special kind of caring. It offers individuals with life-limiting illnesses a choice to live as fully as possible in the comfort and dignity of home a choice to stay in a warm, familiar environment, surrounded by family and friends a choice for persons to be in control of their own care when they can no longer benefit from treatment focused on a cure. The Good Shepherd Hospice Philosophy Hospice is a concept of care that affirms life and regards dying as a natural process. Centered on the needs of patients and families, hospice care helps prepare them for a peaceful death. Good Shepherd Hospice provides expertise in pain and symptom management and seeks to enable patients to carry on a comfortable life. A team of physicians, nurses, hospice aides, social services specialists, chaplains and trained volunteers treat the entire person, not just the disease. Family members are taught how to take care of their loved one. When family members who are providing direct care need to take some time to renew their spirit, Good Shepherd Hospice can give them help. Family members are also provided emotional and spiritual support, including grief services in both indi vidual and group sessions, for a minimum of one year following the patient s death. Good Shepherd Hospice Mission Statement The mission of Good Shepherd Hospice is to provide quality palliative care and relieve the suffering of those in our communities affected by life-limiting illnesses and end-of-life issues, maintaining the highest ethical standards, so all may live as fully and comfortably as possible. 1-1

21 1: General Information Good Shepherd Hospice Resource Manual and Care Guide Statement of Defining Principles: Patient Care Values As a not-for-profit health care provider for persons with life-limiting illnesses, Good Shepherd Hospice: Affirms life and neither hastens nor postpones death. Serves individuals of all ages with life-limiting illnesses who reside in Polk, Highlands and Hardee counties, regardless of their ability to pay, and does not discriminate against or refuse treatment to any patient on the basis of race, color, creed, age, gender, marital status, sexual orientation, religion, national origin, or physical or mental disability. Understands the patient, family, life partner and networks of friends are a unit of care and are all active participants in the development of an individualized plan of care. Respects the choices and values of those we serve concerning the quality of life they seek to maintain. Strives to relieve suffering through focusing on the whole person: physically, emotion ally and spiritually. Provides support services for the family, life partner and friends, which continue after the death of the patient. Provides care through an interdisciplinary group consisting of physicians, nurses, hospice aides, social services specialists, chaplains, trained volunteers and other appropriate support staff. Acts within a consistent set of ethical principles: autonomy, beneficence, justice and the integrity of the health care professional. Monitors and assesses quality of patient care and hospice services on a continual basis to improve performance. 1-2

22 Good Shepherd Hospice Resource Manual and Care Guide Notice of Rights and Responsibilities 1: General Information Good Shepherd Hospice is dedicated to support you and your family, provide for your needs, answer your questions and maximize your quality of life. To that end, Good Shepherd Hospice is pleased to give you the information contained in this notice and to provide appropriate care and services. Please feel free to ask questions. Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider s or health care facility s right to expect certain behavior on the part of patients. As a hospice patient, your rights and responsibilities (a) are addressed in section , Florida Statutes, and/or in 42 C.F.R. Part 418, and (b) include those rights and responsibilities set forth below. You may request a copy of the full text of these laws. A summary of your rights and responsibilities follows: Your Rights You have the right to: Be treated with courtesy and respect, with appreciation of your individual dignity, and with protection of your need for privacy; A prompt and reasonable response to your questions and requests; Know who is providing your medical services and who is responsible for your care; Know what patient support services are available, including whether an interpreter is available if you do not speak English; Know what rules and regulations apply to your conduct; Be given information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis; Refuse any care treatment, except as otherwise provided by law; Be given, upon request, full information and necessary counseling on the availability of known financial resources for your care; Know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate. (This right only applies if you are eligible for Medicare); Receive, upon request, an estimate of charges for medical care prior to treatment; Receive, upon request, a copy of an itemized bill and have these charges explained; Impartial access to medical treatment or accommodations, regardless of your race, national origin, religion, handicap, or source of payment; Treatment for any emergency medical condition that will deteriorate from failure to provide treatment; Know if medical treatment is for purposes of experimental research and to give your consent or refusal to participate in such experimental research; Express grievances regarding any violation of your rights, as stated in Florida law, 1-3

23 1: General Information Good Shepherd Hospice Resource Manual and Care Guide through the grievance procedure of the health care provider or health care facility that served you and to the appropriate state licensing agency. Exercise your rights as a patient of the hospice; Have your property and person treated with respect; Voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice; Not be subjected to discrimination or reprisal for exercising your rights. Receive effective pain management and symptom control from the hospice for conditions related to your terminal illness; Be involved in developing your hospice plan of care; Choose your attending physician; Have a confidential clinical record; Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property; Receive information about the services covered under the hospice benefit, including, without limitation, the availability of spiritual counseling services; Receive information about the scope of services that the hospice will provide and specific limitations on those services; Be informed and receive information about your right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at your option, advance directives; Give or withhold informed consent to produce or use recordings, film, or other images of you for purposes other than your care; Have your rights respected during any research, investigation, or clinical trials in which you participate. Additionally, when your hospice care is provided in a hospice inpatient setting, you have the right to: Be free from corporal punishment; Be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. A restraint or seclusion may only be imposed to ensure your immediate physical safety (or the immediate physical safety of a staff member or others) and must be discontinued at the earliest possible time. If a restraint or exclusion is used, you have the right to safe implementation of such restraint or seclusion by trained staff; Receive and restrict visitors; and An environment that preserves dignity and contributes to a positive self-image. 1-4

24 Good Shepherd Hospice Resource Manual and Care Guide Your Responsibilities 1: General Information You are responsible for: Providing to your health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, current medications, and other matters relating to your health; Reporting unexpected changes in your condition to the health care provider; Reporting to the health care provider whether you understand a contemplated course of action and what is expected of you; Following the treatment plan recommended by the health care provider; Keeping appointments and, when you is unable to do so for any reason, for notifying the health care provider or health care facility; Your actions if you refuses treatment or do not follow the health care provider s instructions; Assuring that your financial obligations relating to your health care are fulfilled as promptly as possible; and Following health care facility rules and regulations affecting patient care and conduct. Patient/Representative Complaint Procedure We recognize and respect you as an individual with unique health care needs. We are committed to meeting and exceeding your needs and expectations related to the quality of your care. We want your experience with Good Shepherd Hospice to be a positive one. If you are not receiving the care or service you expect, you are entitled to have your concerns resolved, 24 hours a day, seven (7) days a week. Between the hours of 8 a.m. and 5 p.m., Monday through Friday, all staff report to a manager, who reports to a regional/department director. During other hours, a clinical manager and administrator are both on-call and available by contacting HospiceHelp24. We would like the opportunity to address and resolve your concerns in the most timely manner possible. For any concerns, 24 hours a day, seven days a week, call your team phone number or (863) or If you are unsatisfied in any way, we encourage you to bring your concerns to our attention until they are resolved. All operations in Good Shepherd Hospice are overseen by an Executive Director. If you still feel your needs have not been met, please contact Chapters Health System at (813) or to speak with our Chief Compliance and Clinical Officer. Issues or concerns that have not been resolved to your satisfaction, may also be shared with the Corporate Compliance Alert Line at ; Agency for Health Care Administration (AHCA) at ; or Florida Medical Quality Assurance, Inc. (FMQAI) at ; or The Joint Commission at

25 1: General Information Good Shepherd Hospice Resource Manual and Care Guide Admission to and Discharge from Hospice Admission to Good Shepherd Hospice is voluntary. Hospice care is provided through an agreement between Good Shepherd Hospice, the patient, the person or persons providing the day-to-day care (also known as the primary caregiver(s) and the patient s physician. The patient, if able, is asked to sign an informed consent for care and to participate in an admission interview. (If the patient is unable to provide his/her consent, the legal representative will be asked to provide consent for care.) The Plan of Care is developed to recognize the unique needs of the patient and those involved in the patient's life and assist them in receiving physical, emotional, and spiritual care. The Good Shepherd Hospice staff will work with the patient and family to plan this care. Discharge from Good Shepherd Hospice may occur if: The patient s disease stabilizes. The patient s prognosis improves. The patient moves out of Good Shepherd Hospice s service area or cannot be located. If the patient moves out of the area, a referral to another hospice program can be made by a nurse or social services specialist. There are patient/staff safety issues that impede care delivery and cannot be resolved. The patient/legal representative refuses to allow Good Shepherd Hospice medical staff visits as required by Medicare for certification purposes. The patient/legal representative requests to be discharged. In an Emergency One of the goals of Good Shepherd Hospice is to help patients remain comfortable at home, surrounded by their loved ones. With hospice care a patient s changing condition can be treated at home instead of an emergency room. If there is a change in the patient s condition, or a medical emergency arises, please call: Polk County...(863) or Highlands County... (863) or Hardee County...(863) or Your calls will be answered 24 hours a day, seven days a week. As a part of our HospiceHelp24 program, your phone calls will be answered by a member of the Good Shepherd Hospice team not an answering service. Registered nurses (RNs) can handle simple questions as well as emergencies. If your needs cannot be met over the phone, an RN or other member of the hospice team will be sent to your home to further assess the situation, make the appropriate physician calls and/or patient transfers. For Medicare and Medicaid patients, Good Shepherd Hospice must authorize all medical care, including choice of hospital, in order to be responsible for payment. If your physician determines that you need to be hospitalized, please immediately notify Good Shepherd Hospice. 1-6

26 Good Shepherd Hospice Resource Manual and Care Guide Personal Planning 3: Personal Planning Advance Directives Making Your Choices Known: Using Florida s Advance Directives and Other Alternatives It is the policy of Good Shepherd Hospice to ensure compliance with all state and federal laws regarding Advance Directives and to inform and distribute written information to patients on their right to formulate Advance Directives. Our provision of care to you is not conditioned upon whether or not you have executed an Advance Directive. You have the right to make your own treatment choices. Good Shepherd Hospice encourages you to use Advance Directives to make sure your choices will be honored, even if you can no longer speak for yourself. Under Florida law, an Advance Directive is a witnessed written document or oral statement in which you express your desires with respect to any aspect of your healthcare. Florida law specifically identifies the following three types of Advance Directives: Living Will Designation of Health Care Surrogate Anatomical Gift Instead of (or in addition to) the above Advance Directives, you may also want to consider executing a Durable Power of Attorney which authorizes a person to take certain healthcarerelated actions on your behalf or an official Do Not Resuscitate Order (DNRO) which indicates your desire not to be resuscitated from respiratory or cardiac arrest. The DNRO is a specific yellow form published by the Florida Department of Health. Details on Living Wills, Designations of Health Care Surrogate, Anatomical Gifts, and Durable Powers of Attorney, DNROs (and other related information) are included on the following pages. Also, copies of Good Shepherd Hospice s more detailed policy and guideline concerning Advance Directives will be made available to you or your legal representative upon request. If you have any questions, ask your Good Shepherd Hospice Registered Nurse or Social Services Specialist or you may also consult with an attorney of your choice. If you feel that your right to receive adequate information concerning Advance Directives requirements has not been honored you may file a complaint with the Florida Agency for Healthcare Administration at or with The Joint Commission on Accreditation at

27 3: Personal Planning Good Shepherd Hospice Resource Manual and Care Guide Living Will A Living Will is a witnessed statement (written or oral) in which a competent adult expresses his or her wishes concerning the life-prolonging procedures that should be used in the event he or she (a) has a terminal condition, end-stage condition, or is in a persistent vegetative state, and (b) does not have a reasonable medical probability of recovering capacity. A Living Will cannot and does not authorize euthanasia or assistance in committing suicide. Please note that although the sections below are intended to provide guidance concerning written Living Wills, much of the information applies in a similar fashion to oral Living Wills. It is the policy of Good Shepherd Hospice to ensure care and services provided to our patients and their families honors their wishes and is in accordance with an individualized, written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with your attending hospice physician, and, as appropriate, with you or with a representative and primary caregiver. Who can prepare a Living Will? Any competent adult can prepare his or her own Living Will. Though it is not necessary, it is recommended you consult an attorney for assistance in preparing or reviewing your Living Will. How can I prepare my own Living Will? Talk to Good Shepherd Hospice about medical procedures you don t understand. Talk to your attorney about any legal questions you need clarified. Talk to your family about your wishes (if you so desire). Once you are certain of your wishes, fill out the Living Will form that has been provided in the pocket of this notebook. (Please note: It is not necessary to use the form provided. If you prefer not to use that form, clearly write out your specific wishes about your future medical treatments and healthcare choices on a piece of paper. That document should then be signed and witnessed in accordance with the signature and witness requirements discussed in greater detail below.) Signature requirements When you sign your Living Will, you must do so in the presence of two subscribing witnesses. However, if you are physically unable to sign your Living Will, one of your witnesses must sign for you both in your presence and at your direction. Witness requirements Only one of the witnesses to your Living Will can be your spouse or blood relative. It is recommended that both witnesses be 18 years of age or older. 3-2

28 Good Shepherd Hospice Resource Manual and Care Guide 3: Personal Planning What should I do with my executed Living Will? Once your Living Will is executed, you should provide a copy to your healthcare providers and others who may be involved in your care. In addition, you may want provide a copy of your Living Will to those family members or friends that you would like to inform of your wishes. How do I change or cancel my Living Will? You may change or cancel your Living Will at any time and for any reason by (a) signing and dating a document that expresses your intent to change or cancel your Living Will, (b) physically canceling or destroying your Living Will, (c) orally expressing your intent to change or cancel your Living Will, or (d) executing another Living Will that is materially different from the Living Will you are changing or canceling. Regardless of which method you use to change or cancel your Living Will, it is necessary that you notify anyone to whom you previously provided a copy of your Living Will, your healthcare providers, and others who may be involved in your care, so that your change or cancellation is effective. Designation of a Health Care Surrogate Under Florida law, you can name a Health Care Surrogate to make certain health decisions for you in the event you become incapacitated and are unable to make them yourself. Your Health Care Surrogate will not and cannot make any healthcare decisions for you unless and until you are unable to make them for yourself. What can my Health Care Surrogate do? Once a physician determines that you no longer have the capacity to communicate your decisions concerning your health care, your Health Care Surrogate can do any of the following, unless you instruct otherwise: Make all healthcare decisions on your behalf. A healthcare decision includes (a) consenting to, refusing to consent to, or withdrawing consent to any and all health care (including diagnostic, medical, mental health and surgical treatments), (b) applying for private, government, veterans, or public benefits (such as Medicare or Medicaid) to defray the cost of your health care, (c) accessing and reviewing your records (including medical, financial, and banking records) that are reasonably necessary for the Health Care Surrogate to make decisions involving your health care and to apply for benefits on your behalf, and (d) deciding to make an anatomical gift. Talk with your doctors and other healthcare providers about your condition and care. Authorize the release of information and medical records to appropriate persons to ensure the continuity of your health care. 3-3

29 3: Personal Planning Good Shepherd Hospice Resource Manual and Care Guide Authorize your admission, discharge, or transfer to or from certain health care facilities or programs. Make decisions about withholding or withdrawing life-prolonging treatments. In doing any of the above, your Health Care Surrogate should make only health care decisions that he or she believes you would have made under the circumstances if you were capable of making such decisions. If there is no indication of what you would have chosen, the Health Care Surrogate may consider your best interests. What can t my Health Care Surrogate do? Unless you indicate otherwise in your Designation of Health Care Surrogate (or your Health Surrogate seeks and obtains court approval), your Heath Care Surrogate cannot give consent for: Abortion, sterilization, electroshock therapy, psychosurgery, certain experimental treatments, or voluntary admission to a mental health facility; or Withholding or withdrawing life-prolonging procedures if you are pregnant and your unborn child is not yet viable. Who can be my Health Care Surrogate? You can name any competent adult to serve as your Health Care Surrogate. Though it is not a requirement, many individuals choose to designate a family member or trusted friend to serve as their Health Care Surrogate. When deciding who to designate as your Health Care Surrogate, it is recommended that you choose someone who (a) has expressed a willingness and ability to serve in that capacity and (b) is familiar with your wishes. You may also wish to designate an individual who can serve as an alternate Health Care Surrogate in the event your first choice is no longer willing or able to serve as Health Care Surrogate. How do I complete a Designation of Health Care Surrogate? Once you determine who you would like to name as your Health Care Surrogate (and, if you desire, your alternate Health Care Surrogate), fill out the Designation of Health Care Surrogate form that has been provided in the pocket of this notebook. Please note: It is not necessary to use the form provided. If you prefer not to use that form, clearly identify those person(s) you wish to designate as your Health Care Surrogate on a piece of paper. That document should then be signed and witnessed in accordance with the signature and witness requirements discussed in greater detail on the following page. 3-4

30 Good Shepherd Hospice Resource Manual and Care Guide 3: Personal Planning Signature requirements When you sign your Designation of Health Care Surrogate form, you must do so in the presence of two subscribing witnesses. However, if you are unable to sign the form, in the presence of the two subscribing witnesses, you may direct that another person sign your name. Witness requirements Both of the subscribing witnesses must be adults. Only one of the witnesses to your Designation of Heath Care Surrogate form can be your spouse or blood relative. The person you name as your Health Care Surrogate cannot be a witness. Additionally, it is recommended that the alternate Health Care Surrogate not serve as a witness. What should I do with my executed Designation of Health Care Surrogate? Once your Designation of Health Care Surrogate form is executed, you should provide an exact copy to the person you have named as your Health Care Surrogate. In addition, you may want provide a copy to your alternate Health Care Surrogate, healthcare providers, others involved in your health care, and to your family members or friends who you would like to inform of your designation. How do I change or cancel my Designation of Health Care Surrogate? You may change or cancel your Designation of Health Care Surrogate at any time and for any reason by (a) signing and dating a document that expresses your intent to change or cancel your Designation of Health Care Surrogate, (b) physically canceling or destroying your Designation of Health Care Surrogate, (c) orally expressing your intent to change or cancel your Designation of Health Care Surrogate, or (d) executing another Designation of Health Care Surrogate that is materially different from the Designation of Health Care Surrogate you are changing or canceling. Regardless of which method you use to change or cancel your Designation of Health Care Surrogate, it is recommended that you notify anyone to whom you previously provided a copy of your Designation of Health Care Surrogate, your healthcare providers, and others who may be involved in your care, so that your change or cancellation is effective. Please carefully consider who you will entrust as your Health Care Surrogate. This person is to represent you and your wishes. 3-5

31 3: Personal Planning Good Shepherd Hospice Resource Manual and Care Guide Power of Attorney A Power of Attorney is a written document in which a principal authorizes another person (called an agent ) to act on the principal s behalf. Unlike a Health Care Surrogate, who can only be appointed to make health care decisions when the person who appointed him or her becomes incapacitated, an agent under a Power of Attorney can perform a variety of activities, such as making financial, legal, or healthcare decisions. Additionally, any Power of Attorney executed on or after October 1, 2011, must authorize the agent to act immediately upon execution and cannot be conditioned upon some future occurrence. Therefore, in Florida, you can no longer execute a Power of Attorney that takes effect only after you become incapacitated. However, you are still allowed to create a durable Power of Attorney, which means that the agent can continue to act on your behalf even after you become incapacitated. To make a Power of Attorney durable you must include certain language that is required by law. If the required language is not used, the Power of Attorney automatically terminates when you become incapacitated. If a principal wants to appoint his or her agent to make health care decisions, such authority must be specifically included in the Power of Attorney. Because of the complex legal nature of Powers of Attorney, it is highly recommended that you consult with an attorney of your choosing prior to executing such a document. Do Not Resuscitate Order (DNRO) Form A Do Not Resuscitate Order (DNRO) Form (Florida Department of Health Form 1896, Revised December 2004) is a type of physician s order designed to advise emergency personnel and other healthcare providers that you do not wish to have cardiopulmonary resuscitation (CPR) or related procedures in the event you experience respiratory or cardiac arrest. In order to be considered valid, a DNRO Form must be printed on yellow colored paper, and then signed by you (or your legal representative) and a Florida licensed physician. Once properly completed, the DNRO Form should be kept in a noticeable, easily accessible place (such as at the head or foot of your bed, on the wall by your bed, or on your refrigerator). It should be readily available in the event of an emergency to ensure that your last wishes will be honored. To learn more about DNRO Forms, please visit or contact your Good Shepherd Hospice social services specialist. 3-6

32 Good Shepherd Hospice Resource Manual and Care Guide Good Shepherd Policy Related to Your Wishes 3: Personal Planning It is important to talk to your doctor about the pros and cons of cardio-pulmonary resuscitation (CPR). If you do not want CPR, your doctor can initiate a Do-Not-Resuscitate order (DNR). Once this document is signed by you and your doctor, you will receive a yellow DNRO to display in your home so emergency personnel and other health-care professionals may honor your wishes. If a medical emergency arises and someone calls 911, emergency personnel will not attempt CPR and will provide comfort measures only. If you do not have a Florida DNRO yellow form executed and you choose to have cardiopulmonary resuscitation (CPR), it is the policy of Good Shepherd Hospice to initiate CPR and call 911 for emergency assistance. Your Rights It is the policy of Good Shepherd Hospice to ensure compliance with all state and federal laws regarding Advance Directives. If you have a question or concern related to your rights about Advance Directives, you are encouraged to contact your team RN Care Coordinator for a referral with the team social services specialist. Anatomical Gifts An Anatomical Gift is a donation of your body or part of your body (e.g., your organs, eyes, or tissue) to take effect after your death and to be used for transplantation, therapy, research, or education. If you would like to learn more about Anatomical Gifts, please visit the Joshua Abbott Organ and Tissue Donor Registry at Advance directive forms are provided in the pocket of this notebook. If you have any questions about information in this section, contact Good Shepherd Hospice. 3-7