ADMISSION.Legal Guardian Signature by X's- Financial Guarantor by 0'.S -Client Signs by Resident
PLEASE USE THIS GUIDE FOR COMPLETING ADMISSION PAPERWORK BRING ALL LISTED PAPERWORK TO THE
ADMISSION.Legal Guardian signature by X's- Financial guarantor by 0'.s -Client signs by Resident
PAGE 1: Guide for completing paperwork
PAGE 2: Documentation requested for Medical Record
PAGE 3: Consent for Treatment, front side
PAGE 4: Consent for Treatment, back side
☐List all payers in the insurance and age cy spots (i.e. primary=Medicaid, secondary=CSA)
☐Have legal guardian sign as legal guardian
☐Have a representative of paying agency sign as financial guarantor and educational guarantor
PAGE 5: Insurance explanation
☐Have legal guardian sign as legal guardian
☐Have a representative of paying agency sign as financial guarantor
PAGE 6: Intent To Fund Services Agreement
PAGE 7: CSA Virginia Medicaid rate reimbursement sheet for RTC only
PAGE 8: Current FY Rate Sheet
PAGE 9: Notice of Rights, front side
PAGE 10: Notice of Rights, back side
☐Have legal guardian sign as legal guardian
PAGE 11: Written Placement Agreement
☐Answer questions 8-10 about previous vaccinations
☐List all medications currently prescribed
☐Have legal guardian sign as legal guardian
PAGE 12: Physical Hold Video Surveillance explanation
☐Have legal guardian sign as legal guardian
PAGE 13: Release of Information for guardian
☐Write legal guardian's name where specified
☐Write resident's name and birth date where specified
☐Have legal guardian sign as legal guardian
PAGE 14: Release of Information for GAL
☐Write GAL's name where specified
☐Write resident's name and birth date where specified
☐Have legal guardian sign as legal guardian
PAGE 15: Release of Information for PO
☐Write PO's name where specified
☐Write resident's name and birth date where specified
☐Have legal guardian sign as legal guardian
PAGE 16: Release of Information for educational information
☐Write school name where specified
☐Write resident's name and birth date where specified
☐Have legal guardian sign as legal guardian
PAGE 17: Release of information for other involved party
☐Write person's/agency's name where specified
☐Write resident's name and birth date where specified
☐Have legal guardian sign as legal guardian
PAGE 18: Admission Behavior Report
☐Complete entire report, note that ENTIRE second box pertains to the 7 days prior to admission to
Hallmark Youthcare - BE AS SPECIFIC AS POSSIBLE
PAGE 19: Treatment Team Authorization Log
☐Add the names and addresses of any person that should be invited to staffingsor receive copies of treatment plans
PAGE 20: Anticipated Upcoming events
☐Add any significant upcoming events
PAGE 21: Phone and Visitation Authorization
☐Add all people (including legal guardian and family) that are allowed to visit or phone the resident
☐Have legal guardian sign as legal guardian
PAGE 22: Mental Health Outcomes Release of Information Form
☐Write resident's name and date of birth where specified.
☐Write legal guardian's information in "First Collateral Source" section
☐Have legal guardian sign as legal guardian
PAGE 23: Mental Health Outcomes-Columbia Impairment Scale
☐To be completed by Parent/Guardian
PAGE 24: Mental Health Outcomes-Columbia Impairment Scale- to be completed by Resident
PAGE 25: Admission Medication Reconciliation form. Legal Guardian to complete and sign
PAGE 26: Packing list-authorized possessions list
PAGE 27: Directions
DocumentationrequestedforMedicalRecord
Please bring copies of each, originals can be copied on admission if needed
•BIRTHCERTIFICATE
•SOCIAL SECURITYCARD
•DOCUMENTATION OF CUSTODY, COURTORDER
•MOST RECENT IMMUNIZATIONRECORD
•MOST RECENT DENTALRECORD
•MOST RECENT HISTORY ANDPHYSICAL
•SCHOOLRECORDS/GRADES/SCHEDULE/IEP
•VIRGINIA MEDICAID CARD AND OTHER INSURANCE RESIDENTISCARRIED ON (ANY PARENTALINSURANCE)
•RTC VIRGINIA MEDICAID AUTHORIZATION REQUIRED- CON,CANSAND CSA RATE REIMBURSEMENTSHEET
•RULES OF PROBATION IFAPPLICABLE
*****If resident is carried by a parental insurance and the information isnotprovided to Hallmark Youthcare, Medicaid will deny all claims and the CSAwillberesponsibleforthebilluntiltheinsuranceinformationisprovided.*****
Hallmark Youthcare - Richmond
Consent forTreatment
The undersigned authorizes the HALLMARK YOUTHCARE - RICHMONO (FACILITY), its' staff, and attending physicians to render to the resident all customary care, therapy, treatment, tests and procedures considered advisable, including emergency treatment and transportation to another facility if necessary. Further consent is also given for any educational testing, diagnostic procedures, medical treatment, recreational activities and therapy, and other treatment ordered by the attending physician including, but not limited to, services provided by 0U1er Healthcare Professionals to the resident.
The undersigned affirms that he/she has retained no other medications on his/her person and- agrees that all medications must be dispensed by the pharmacy or by a trained and authorized employee while he/she is on the premises of THE FACILITY.
The undersigned acknowledges certain healthcare professionals furnishing services to the resident, including, but not limited to, psychiatrists, psychologists, physical therapists, social workers , and/or counselors may be independent contractors and may not be employees or agents of THE FACILITY. The undersigned further recognizes that the resident may be billed separately by their attending physicians and/or other healthcare professionals for their services provided.
Consent for Admission to HallmarkYouthcare
The undersigned acknowledges that no guarantee or assurance has been made to them, or the resident, as to the_ results of any services provided to the resident, including, but not limited to therapy, treatment, tests or procedures, while a resident of THE FACILITY. The undersigned further understands that, unless otherwise disclosed, THE FACILITY, does not employ physicians and that the resident's admitting physician(s), or a physician to whom the resident may be referred and any o1her physician who may consult or provide services to the resident are not employed by and are not agents of THE FACILITY, but are independent physicians who exercise their Judgement in the services they render to residents.
The undersigned consents to the taking of photographs for the purpose of identification. These photographs may be permanently retained in the resident’s medical record.
Consents for Release ofInformation
The undersigned authorizes THE FACILITY to release all resident information, including specific information regarding diagnosis, treatment, and prognosis with respect to any physical, psychiatric, or drug/alcohol related condition for which the resident is being treated, including treatment for Acquired Immune Deficiency Syndrome (AIDS) . while al THE FACILITY, to any insurance company, and/or third party payors, or representative providing coverage for this admission, or to any FACILITY representative including, but not limited to employees, attending physicians, other healthcare professionals and organization$ .This information may not be released to any other person or entity unless the undersigned so authorizes.
The undersigned acknowledges that such disclosures shall be limited lo information that is reasonably necessary for the discharge of the legal or contractual obligations of the person(s) or entities to which the information is released.
The undersigned further authorizes THE FACILITY to release information for the purpose of obtaining pre-authorization for residential treatment and concurrent review and to release that information to medical review agencies and/or third party payors providing coverage or having responsibility for this admission.
The confidentiality of alcohol and drug abuse resident records is protected by Federal law and regulations, Generally, THE FACILITY may not disclose information to anyone outside THE FACILITY which would IDENTIFY any resident as an alcohol or drug abuser unless the resident has consented in writing; the disclosure is allowed by court order, or the disclosure is made to medical or other qualified personnel in accordance with Federal regulations.
Federal law and regulations do not protect information regarding a crime or a threat to commit a crime or any information regarding suspected child abuse or neglect from being reported appropriate State or local authorities.·
The undersigned also hereby authorizes free exchange of medical record information, 'including, but not limited to the release of resl4enUnformation indicated above between THE FACILITY and the attending physician, his/her group practice association, and/or other health care ,agencies, facilities and/or professionals which may provide services to resident during this admission.
The undersigned may request to receive a copy of this Authorization for release of information and may revoke this Authorization at any time, except to the extent that action has been taken in reliance thereon. The undersigned acknowledges that this authorization shall be valid until all third party payers liability is resolved for this admission.
Consent for Follow-upContact
The undersigned consent(s) to THE FACILITY, staff members or other healthcare professional contacting the resident or a family member by telephone in approximately six months to one year. THE FACILITY makes periodic contact with those who have used its' services, using the information to improved Its' services to residents and to make sure THE FACILITY is addressing residents' needs. Specific responses are not disclosed; only summary information is assembled. His contact may also include, but not be limited to, information sent from THE FACILITY on current educational programs and newsletters .
Acknowledge Receipt of ResidentRights
The undersigned acknowledges that a copy of the Resident Rights has been given to them, that these rights have been explained, and that they understand these rights.
Responsibility forDestruction ofProperty orLostProperty
The undersigned acknowledge(s) that residents are responsible for any damage to or destruction of THE FACILITY property, or property belonging to others which may be located at THE FACILITY The undersigned agree t0 accept liability for, and reimburse THE FACILITY or other owners of, property which the resident may damage or destroy. The undersigned acknowledges that they have received a copy of the prohibited items of THE FACILITY and that they are not bringing any of those. Items onto FACILITY property. The undersigned acknowledges that THE FACILITY is not responsible for personal • items that are damaged or lost or not removed within 30 days of discharge while a resident of THE FACILITY.
Consent for HIVTesting
Theundersignedacknowledgesthatwheneverastaffmember,resident.oranyperson employedbyorunderthedirectionofTheFacility,isdirectlyexposedtobodyfluidsofaresidentinamannerwhichmaytransmitHIV,theresidentwhosebodyfluidswhichwasinvolvedintheexposureshall bedeemedtohaveconsentedtotestingforHIVinfection.Theresidentisalsodeemedtohaveconsentedtothereleaseofthisinformationtothestaffmember who wasexposed.
Assignment of Insurance Benefits
In consideration of residential and medical services rendered or to be rendered by THE FACILITY, to the extent permitted by law, I hereby irrevocably assign, transfer and set over to THE FACILITY all of my rights, title and interest to medical reimbursement, including, but not limited to the right to designate a beneficiary, and dependent eligibility and to have an individual policy continued or issued in accordance with the terms aride benefits under any insurance policy, subscription certificate or other health benefit indemnification agreement otherwise payable to me for those services rendered by THE FACILITY during the pendency of the claim for this admission. Such irrevocable assignment and transfer shall be for the recovery on said policy(ies) of insurance, but shall not be construed to be an obligation of THE FACILITY to pursue any such right of recovery. THE FACILITY will pursue appeal of denied claims through two levels of appeal. I hereby authorize the insurance company(ies) of third party payor(s) to pay directly to THE FACILITY all benefits dues to services rendered.
PRIMARYINSURANCEIAGENCYNAME:______☐COPYPROVIDED
SECONDARYINSURANCE/AGENCYNAME: ______☐COPYPROVIDED
EDUCATIONALFUNDING:______
FACILITY Discharge PolicyInformation
The undersigned understands that it is the policy of THE FACILITY to attempt to provide a structured therapy regimen with effective quality treatment.
If the treatment regimen is not completed prior to the exhaustion of a resident's health insurance benefits, the undersigned agrees to be liable for
any charges incurred which are not paid by insurance in addition to the deductible and/or copayment liability. It is NOT the policy of THE FACILITY to discharge, transfer or end treatment regimens of a resident when insurance has been exhausted.
Guarantee ofPayment
The undersigned, hereby agrees to guarantee payment of the bill for services, including room and board, medical, counseling, daily supervision, physician, therapy and education services, rendered by THE FACILITY from admission to discharge. The undersigned agrees whether signing as guarantor, legal guardian, or as patient, that in consideration of the services to be rendered to the resident, to be hereby jointly and individually obligated to pay the account of THE FACILITY in accordance with the regular rates and terms of THE FACILITY. Should the account be referred for collection by an attorney or collection agency, the undersigned agree(s) to pay all attorney's fees and other reasonable collection costs and charges that are necessary for the collection of any amount{s) not paid when due.
Consent for Transportation to Therapeutic trial visits/field trips/facility activities/medical appointments/court
The undersigned hereby acknowledges that the resident's attending physician may include in the treatment of a resident activities or field trips away from THE FACILITY and that the attending physician may all times allow the resident therapeutic trial visits away from THE FACILITY. In consideration of the value to the resident of such treatment, the undersigned hereby: (1) consent to the resident's participation in field trips, activities, medical appointments/court and therapeutic trial visits; (2) release THE FACILITY, its' employees and its' agents from all liability for injury to the resident caused by any act or omission on their part in the course of such field trips, activities. and leaves; and (3) agree to indemnify and hold harmless THE FACILITY its' medical staff, its' employees and its' agents from all claims, costs, losses incurred as a result of any act of the resident while on such field trips, activities and leaves.
The undersigned also acknowledges they have been informed of THE FACILITIES transportation policies to include passenger management of emergencies, vehicle maintenance and safety and driver qualifications. The facility does not provide transportation to and from school.
Advance Directive Acknowledgement
The undersigned acknowledges: (1) 1 have been given materials about my right to accept or refuse medical treatment; (2) 1 have been informed of my rights to formulate Advance Directives; (3) 1 understand that Iam not required to have an Advance Directive in order to receive medical treatment at this FACILITY; and (4) 1 understand that the terms of any Advance Directive that I have executed will be followed by THE FACILITY and my caregivers lo the extent permitted by law.
☐ I HAVE☐IHAVE NOT executed an Advance Directive
Applicabilitytootherproviders
The undersigned agree(s) that in the event other healthcare professional providers, including but not limited to other facilities, furnish services to the resident while in THE FACILITY the consent(s), assignment(s). guarantee(s), and release(s) herein set above set out shall apply to such other
providers and services.
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RESIDENT'SNAMERESIDENTSSIGNATUREDATETIME
______
LEGAL GUARDIANNAMELEGAL GUARDIANSIGNATUREDATETIME
______
GUARANTOR NAME/AGENCYGUARANTOR SIGNATUREDATETIME
______
FACILITYSTAFFNAMEFACILITYSTAFFSIGNATUREDATETIME
______
EDUCATIONAL GUARANTORNAMEGUARANTORSIGNATUREDATETIME
White –Chart Yellow-Parent/Guardian Pink –Resident Gold-CACGreen -Business REV:3/2009
Hallmark Youthcare -Richmond
In all cases where the proposed treatment plan includes services that are determined not medically necessary according to a third party payor, the Utilization Review department will initiate an appeal of this decision (when the attending physician feels admission/continued care is clinically indicated). If such conflict arises treatment and discharge decisions will be made in response to the care required by the individual, regardless of the external agency's recommendation. Hallmark Youthcare involves the individual (when not clinically contraindicated) and, as appropriate, the individual'sfamily/guardian in deliberations about care decisions. Hallmark Youthcare will pursue two levels of appeal.
If an admission/continued stay review indicates admission/continued stay criteria has not been met. the case will be referred to a physician advisor (as outlined in the facility's Utilization Review Plan). When admission/continued stay is deemed inappropriate by
this review mechanism, the Medical Executive Committee will send a letter to the resident (if appropriate) and/or legal guardian/sponsor explaining the reasons for the denial and will contain the administrator's signature. A copy will be sent to the attending physician and the appropriate Medicaid agency.
I have read and understand the practices and policies of Hallmark Youthcare regarding third party payor denials_
______
RESIDENT'SNAMERESIDENTSSIGNATURE DATETIME
______
LEGAL GUARDIAN NAMELEGAL GUARDIASIGNATURE DATETIME
______
GUARANTOR NAME/AGENCYGUARANTOR SIGNATURE DATETIME
______
FACILITYSTAFFNAME FACILITYSTAFFSIGNATURE DATE TIME
HALLMARKYOUTHCARE-RICHMONDCLINICAL ASSESSMENTCENTERPHONE (804)784-6432 FAX (804)784-5261
INTENTTOFUNDSERVICESAGREEMENT
______confirmstheintenttofund ______
(Agency)
(Resident)
ForplacementatHallmarkYouthcare-Richmondbeginningon______and endingon ______
ServiceRate per day
Residential Treatment Services
Assessment & Diagnostic Services
Physician/Therapy Services
School
*****If resident is carried by a parental insurance and the information isnotprovided to Hallmark Youthcare, Medicaid will deny all claims and the CSA willberesponsibleforthebill untiltheinsuranceinformationisprovided.*****
______
Agency RepresentativeHallmark Youthcare Representative
______
PhoneNumberPhoneNumber
______
DateDate
CSAReimbursementRateCertification
ResidentialTreatment
Name of Child: ______
Medicaid Number: ______
Residential Treatment Provider:
______
Address:______
Street
______, ______, ____
City State Zip
Provider Number:
Community Policy and Management Team:
County/City: ______
Address:______
Street
______, ______, ____
City State Zip
I certify that the following rate, per day, has been negotiated for the above-named child for Medicaid reimbursable Residential Treatment (check one:
☐Residential Treatment
☐Treatment Foster Care Case Management
The Medicaid rate noted above should reflect the negotiated rate minus expected reimbursement from all other payment sources, such as Title IV-E. The total of the reimbursement from all other sources cannot exceed the Medicaid maximum rate for this service. This rate shall be effective for dates of service beginning on