PROFESSIONAL PEDIATRIC HOME CARE
CONSENT FOR TREATMENT
CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
Patient Name: ______Birth Date: ____/____/____
MM/ DD / YR
Address:______
______
CONSENT FOR TREATMENT
I hereby consent to the provision of services encompassing examination, routine care, diagnostic procedures, medical social work, nursing and other therapeutic services by Professional Pediatric Home Care. I authorize the health professionals to take such actions as are necessary and desirable in the exercise of professional judgment.
I acknowledge that no guarantees have been made to me as to the extent of examination, treatments or therapies.
I understand that Professional Pediatric Home Care assumes no responsibility or liability for any other person, adult or child, in this home except for the one contracted for per this agreement.
CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
1.Permission to Use and Disclose Your Health Information. By signing this consent, you authorize us to use and/or disclose your health information for treatment, community resource planning, payment (including claim appeals processing) or health care operations. You have the right not to sign this consent. However, if you refuse to sign this consent, we have the right to refuse to treat you.
2.Your Rights With Respect to This Consent.
2.1.Right to Review Notice of Privacy Practices. You have the right to review a copy of our Notice of Privacy Practices before signing this consent. Our Notice of Privacy Practices details how we may use and disclose your health information. We may amend the Notice from time to time. You may obtain a copy of our Notice of Privacy Practices, including any revisions we have made by contacting the PPHC Compliance Officer at (303) 759-1342.
2.2.Right to Request Restrictions on Use/Disclosure. You have the right to request that we restrict how we use and/or disclose your protected health information for the purpose of providing treatment, obtaining payment for our services, and/or conducting health care operations. Such requests must be made in writing. Please note that we are not required to agree to any restriction you may request. If, however, we decide to agree to a restriction youhave requested, we must restrict our use and/or disclosure of your health information in the manner described in your request. To obtain a restriction request form, please contact the PPHC Compliance Officer at 8000 E Prentice Ave, B11, Greenwood Village, CO 80111.
2.3.Right to Revoke Consent. You have the right to revoke this consent at any time. Your revocation of this consent must be in writing. If you wish to revoke this consent, please contact the PPHC Compliance Officer,8000 E Prentice Ave, B11, Greenwood Village, CO 80111to obtain a revocation form. Note that your revocation of this consent will not be effective for disclosures we have already made in reliance on your prior consent. We also have the right to refuse to provide further treatment if you revoke this consent.
2.4Right to Receive a Copy of This Consent Form. You have a right to receive a copy of this consent form after you sign it.
3.Effective Period. This consent is effective unless and until you revoke it in writing.
I hereby authorize Professional Pediatric Home Care to provide treatment as stated above and to use and/or disclose my health information for treatment, payment, or health care operations.
______/_____/_____
Patient Signature or Parent/Guardian if patient is under 18 Date
______
If Parent/Guardian, relationship to patient

PLEASERETURN TO PPHC

PROFESSIONAL PEDIATRIC HOME CARE

PATIENT NAME:______

I have received the Client’s Bill of Rights from Professional Pediatric Home

Care. An agency representative has reviewed this with me. I understand the

patient’s rights.

Emergency Contact Information:

In the event of an emergency or unforeseen circumstance, please list all emergency contacts:

Parent/s or guardian names and all contact phone numbers:

______

______

______

Names and phone numbers for any other qualified caregivers:

______

______

If a non life threatening emergency or an unforeseen circumstance occurs in which the patient caregiver is not able to care for the patient while a PPHC provider is present, the PPHC provider will first attempt the emergency contacts listed above and if no one is available, will then Dial 911. If a life threatening emergency occurs the provider will first call 911 and then attempt emergency contacts.

I have reviewed and agree with the above statements.

Signature of Guardian:______Date:______

Signature of Agency:______Date:______

PROFESSIONAL PEDIATRIC HOME CARE

8000 E. Prentice Avenue, B11 Greenwood Village, CO 80111

(303) 759-1342 Fax: (720) 493-4632

Dear Families,

Medicaid requirements necessitate that we know immediately if:

  1. Your child changes doctors.
  2. Your child’s insurance changes in ANY way.
  3. Your Child’s Medicaid status changes.
  4. You receive services from an additional home care agency or your doctor recommends an additional service. (Medicaid requires all home care services be provided by one agency unless the first agency cannot supply a service.)
  5. Your child’s health status becomes “acute”. Medicaid defines an acute episode as one that involves.
  • Infections
  • New medical conditions such as, but not limited to, stroke, injury, pressure sores.
  • Health concerns requiring hospitalization.
  • Return to home after being hospitalized.
  • Exacerbation of a chronic condition (such as increasing seizures).
  • New diagnosis of a long-term chronic condition (such as diabetes).
  • Complications of pregnancy.

Please call immediately with any of the above information to (303) 759-1342.

Feel free to call with any questions!

Leave in patient’s home

PROFESSIONAL PEDIATRIC HOME CARE

Patient’s Bill of Rights/Responsibilities

The patient and family have the right to:

  1. Be fully informed of all his rights and responsibilities by the home care agency.
  2. Appropriate, timely and professional care relating to physician orders without discrimination against race, creed, color, religion, sex, national origin, sexual preference, or handicap.
  3. Be treated with courtesy and respect by all who provide home health care services to you.
  4. Participate in the choice of care providers.
  5. Be given proper identification by name and title of everyone who provides home health care services to you.
  6. Receive information necessary to give informed consent prior to any procedure or treatment.
  7. Confidentiality of all records, communications, and personal information.
  8. Review clinical record at their request.
  9. Refuse treatment within the confines of the law and to be informed of the consequences of his action.
  10. Privacy and protection of his/her property.
  11. Receive a timely response from the agency to his request for service.
  12. Reasonable continuity of care. A patient will be admitted for service only if the agency has the ability to provide safe professional care at the level of intensity needed.
  13. Voice grievances and suggest changes in service or staff without fear or restraint or discrimination.
  14. A fair hearing shall be available to any individual to whom service has been denied, reduced or terminated or who is otherwise aggrieved by agency action. The fair hearing procedure is set forth as appropriate to the patient’s situation (e.g. funding source, level of care, diagnosis).
  15. Be fully informed of agency policies and charges for services, including eligibility for third party reimbursement. A patient denied service solely on his inability to pay has the right to be referred elsewhere.
  16. Honest, accurate and forthright information regarding the home care industry in general and his chosen agency in particular.
  17. Be given information regarding anticipated transfer of home health care to another health care facility and/or termination of home health care services.
  18. Be informed and participate in planning care and treatment in advance. The patient/family will be informed of treatment frequency and duration proposed and any changes in plan of care in advance.
  19. A toll-free Home Health Hotline is available in this state to receive complaints or questions about local home health agencies. The hotline number is 1-800-842-8826. Currently this is recording. The caller is asked to leave their name and number. Someone will respond during the working hours of 8 a.m. to 5 p.m.

Responsibilities of the home care recipient and family are:

  1. Give accurate and complete health information concerning past illnesses, hospitalization, medications, allergies and other pertinent items.
  2. Assist in developing and maintaining a safe environment.
  3. Inform our program when you will not be able to keep a scheduled visit or shift, or there is a change in your child’s condition.
  4. Participate in the development and update of the home health care plan and teaching plan.
  5. Adhere to the home health care plan and/or family contract.
  6. Request further information concerning anything that is not understood.
  7. Give information regarding concerns and problems you have to a home care staff member.

I have read Professional Pediatric Home Care Patient Bill of Rights/Responsibilities, and understand my rights/responsibilities as a client receiving home care services from Professional Pediatric Home Care. This information was presented to me prior to, or at the time of the initial evaluation.

______

Signature of GuardianRelationship to PatientDate