- Client acknowledges that travel outside of city limits will equate to $0.50 KM invoiceable to the client and/or travel with the client within city limits will be reimbursable at the same rate
- Client acknowledges that a cancellation fee is applied if an employee arrives for a scheduled shift or if less than 24-hours of notice is provided prior to the scheduled start time of the visit
- Our rates are subject to change by Ohana Care upon thirty (30) days written notice
Authorization for Emergency Medical Services:
- I understand that Ohana Care providers are trained to respond to medical emergency situations and will call for additional emergency medical help if needed. In the event of a medical emergency occurring during my assessment, treatment, or other services, all reasonable efforts will be extended to assist in my recovery.
- I understand that I, or my duly authorized representative, is required to declare any special instructions with respect to emergency medical intervention, such as the existence of a “Living Will” or “DNR” order prior to commencing my services with Ohana Care.
Consent to Assessment, Treatment, and Healthcare Services:
- I hereby authorize Ohana Care to provide me with an assessment and treatment or to render other healthcare services. The purposes of the assessment and treatment procedures or other health care services have been explained to me.
- I understand that the treatment plan, goals, and anticipated benefits have been discussed with me and I have been given the chance to ask any questions I may have about my treatment.
- I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying me of my termination and the reason. I acknowledge receipt of the Client’s Bill of Rights.
Consent for Photographic Image:
- I hereby consent and authorize an employee or representative of Ohana Care to take a photographic image of my likeness, to be stored in both electronic and physical files for the sole purpose of identity crosscheck at the time services are rendered. We will not share, rent, nor sell the information you provide us herein.
Scheduling of Staff:
- I understand that the services provided by Ohana care will be scheduled directly through Ohana Care offices and that I nor my representatives will schedule through caregiver.
- I understand that Ohana Care caregivers are directed not to schedule care directly with myself or appropriate family members. All modifications to scheduling will be coordinated directly through Ohana Care offices.
Consent to the Collection, Use, and Disclosure of Personal or Personal Health Information:
- I understand that to provide me with services, Ohana Care will collect personal information about me (for example, name, telephone number, address and personal health number) only to the extent necessary for the services Ohana Care provides.
- I understand this information may be shared with a Health Information Custodian.
- I understand that I may withdraw my consent in whole or in part at any time by notifying my Ohana Care service provider and that my withdrawal of consent is not retroactive to information that is already collected, used or disclosed by Ohana Care.
- I have received information about Ohana Care’s Privacy Policy and I understand how Ohana Care’s Privacy Policy applies to me.
- I consent to Ohana Care collecting, using and disclosing personal or personal health information about me as set out above and in accordance with Ohana Care’s Privacy Policy.