CONSENT TO TREATMENT/ASSIGNMENT OF BENEFITS
Terms of Agreement and Medical Treatment Consent: I understand that by signing this agreement, I authorize provision of products, services and/or care to me by University of Iowa Community HomeCare (UICH). If my care has been ordered by a physician, I understand that I am under the control of my attending physician and that UICH is not liable for any act or omission when following the instructions of said physician.
Assignment of Benefits/Financial Responsibility: I authorize (a) direct payment to UICH of any insurance benefits otherwise payable to me for Equipment provided by UICH, (b) my insurance UICH to furnish to UICH all information pertaining to my insurance benefits and status of claims submitted by UICH for Equipment provided, and (c) UICH to release to my insurance company(ies) (or CMS and its agents) any and all information pertaining to me for benefit determination. While insurance coverage may exist for the Equipment provided by UICH to me, I recognize that all Equipment may not be covered, or that reimbursement may be less than 100% of charges billed, in accordance with my coverage. Therefore, I agree to be financially responsible for any balance owing on my account including all co-payments and deductibles. In addition, I agree, unless I am a Medicare recipient and UICH has accepted assignment or I am a Medicaid recipient, to immediately pay the full amount due to UICH if (a) no payment is received by the UICH within 30 days from the date UICH submits a claim, or (b) my physician or I fail to provide UICH with information necessary to submit the claim. I agree to transfer immediately to UICH any payment made directly to me for Equipment provided by UICH on an assigned basis. I agree that should UICH decline to accept assignment of my benefits from Medicare or any other payor, I will pay the full amount due to UICH.
Notice of Privacy Practices: I understand that I have the right to review the agency’s Notice of Privacy Practices prior to signing this consent. I acknowledge that I have been referred to, and have received, a copy of the Agency’s Notice of Privacy Practices which summarizes the ways my medical record may be used or disclosed by the agency and states my rights with respect to my medical information. I understand that the Agency has the right to revise its information practices and to amend the Notice. I have been informed that in the event the Agency revises its information practices, a revised Notice will be mailed to my last known address and that I may obtain a current Notice at any time from UICH.
Right to Restrict Disclosures: I understand that I have the right to restrict how the Agency uses and discloses all or any part of my medical record for treatment, payment or health care operation. I further understand that the Agency does not have to agree to such restrictions. I understand my request to restrict disclosures must be made in writing to the Agency.
Right to Revoke At Any Time: It has been explained to me that I have the right to revoke this consent at any time. I understand that any revocation by me of this consent will only apply to future uses and disclosures of my medical record. Such revocation is not effective for previous uses and disclosures which occurred prior to the revocation.
Patient/Client Bill Of Rights and Responsibilities: I have received, read and understand my Bill of Rights and Responsibilities.
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Signature of Patient/Guardian/Legal Representative Date Signed
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Full Name, Address, and Relationship of Guardian/Legal Representative to Patient
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Reason Patient Unable to Sign
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Signature of Witness /Full Name and Address Date Signed
If Interpreter Required:
The undersigned certifies that he/she has read and explained the forgoing to the patient or their duly authorized agent or representative in the patient’s primary language, ______, and that said patient, agent or representative expressed understanding of the forgoing.
Interpreter: ______
Bill of Rights
As a patient/client of UICH, you have rights, which include, but are not limited to the following:
1. Be given information about your rights for receiving services and any limitations in service.
2. Receive a timely response from UICH regarding your request for homecare services.
3. Be given information regarding charges for services as outlined on your Financial Agreement Arrangements.
4. Choose your homecare providers.
5. Be given appropriate and professional quality homecare services without discrimination regardless of age, race, color, sex, religion, ancestry, national origin, mental and physical handicap, sexual orientation and/or medical diagnosis.
6. Be treated with courtesy and respect by all who provide homecare services to you.
7. Be informed of any financial benefits when referred to another organization.
8. Be given proper identification by name and title of everyone who provides homecare services to you.
9. Be given the necessary information so you will be able to give informed consent for your service prior to the start of any services.
10. Be given complete and current information concerning your diagnosis, treatments, alternatives, risks and prognosis as required by your physician’s legal duty to disclose in terms and language you can reasonably be expected to understand.
11. A plan of service that will be developed to meet your unique service needs.
12. Participate in the development and revision of your plan of care/service.
13. Be given an assessment and update of your developed plan of care/service.
14. Be given data privacy and confidentiality.
15. Review your clinical record at your request.
16. Be given information regarding anticipated transfer of your homecare to another healthcare facility and/or termination of homecare service to you.
17. Voice grievance with and/or suggest change in homecare services and/or staff without being threatened, restrained, and discriminated against.
18. Refuse treatment within the confines of the law or contract if applicable.
19. Be given information concerning the consequences of refusing treatment.
20. Have an advance directive for medical care, such as a living will or the designation of a surrogate decision maker, respected to the extent provided by the law.
21. Participate in the discussion of ethical issues that arise in your care.
22. Be informed of anticipated outcomes of care and of any barriers in outcome achievement.
Responsibilities
UICH and its personnel have the right to expect from you, our patient, your relatives and friends, reasonable behavior which takes into consideration the nature of your illness or predicament. These responsibilities include, but are not limited to the following:
1. Give accurate and complete health information concerning you past illnesses, hospitalizations, medications, allergies and other pertinent items.
2. Assist in developing and maintaining a safe environment.
3. Inform UICH when you will not be able to keep a homecare visit.
4. Participate in the development and update of your homecare plan of service/treatment.
5. Adhere to your developed/updated plan of service/treatment.
6. Request further information concerning anything you do not understand.
7. Contact your doctor whenever you notice any change in your condition.
8. Contact UICH whenever you have an equipment problem with equipment provided by UICH.
9. Contact UICH whenever you are to be hospitalized.
10. Give information regarding concerns and problems you have to a UICH staff member.
11. Contact UICH prior to any change of address or phone number.
12. Contact UICH if you acquire any infectious disease during the time you are receiving services and/or care from UICH, except where exempted by law.
13. Treat your healthcare providers with dignity and respect.
7/20/2015