Solace Healthcare Solutions Admission Package

Solace Healthcare Solutions, LLC

16 Greendale Rd #2, Boston, MA 02126, USA | T: (617) 506-5717 F: (800) 878-6987 | www.solacehealthcare.org
Admission Package
Patient Name *

First NameLast Name
Email
example@example.com
MR#
Attention

Medicare / Medicaid Verification Form
Patient Name*

First NameLast Name
Medicare Claim #
Is Entitled to:
Effective Date:

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Date
Patient Sign Here*

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Medicaid ID Card

Make sure the name is exactly as it appears on the Medicare / Medicaid card.
Visualized Medicare Card:*

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Picture of the Card
Nurse Signature*

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Date*

MonthDayYear
Date

Name

First NameLast Name
MR#
CLARIFICATION OF THE HOMEBOUND DEFINITION UNDER THE MEDICARE HOME HEALTH BENEFIT
"Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration."

To qualify for the Medicare home health benefit, a Medicare beneficiary must be confined to the home, under the care of a physician, receiving services under a plan of care established and periodically reviewed by a physician, be in need of skilled nursing on an intermittent basis, (other than solely venipuncture), or physical therapy or speech language pathology or have a continuing need for occupational therapy.

Physician certification that the beneficiary is confined to his home is an eligibility requirement for all home health services.

I understand that Medicare's definition of "homebound" is "there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort". The new provision expands the list of circumstances in which absences from the home would be consistent with a determination that the patient is "confined to the home" or "homebound" for Medicare purposes, it does not change the existing homebound guidelines beyond the two specific provisions below. The new provisions include:

Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day care services in the State shall not negate the beneficiary's homebound status for the purpose of eligibility.

Any absence for religious service is deemed to be an absence of infrequent or short duration and thus does not negate the homebound status of the beneficiary.

This new statutory provision does not imply that Medicare coverage has been expanded to include adult day care services. I attest that, should my condition so improve that I am no longer confined to my residence, I will promptly report this change in condition to QAZ Home Care agency, LLC immediately at: (508) 219-0101
Patient Signature:*

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Date:*

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Clinician:*

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Date:*

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Date

Patient Name:
MR#
LOCK BOX USE AGREEMENT TO MANAGE MEDICATION COMPLIEANCE
I blanksagree/consent to Solace Healthcare Solutions, LLC implementing to use of a lockbox to assist me in the management of my prescribed medications.

I understand that I will be responsible for any damage to, or loss of the lockbox while it is in my home. I have been informed that any tampering with the locked box may jeopardize my ability to continue services with Solace Healthcare Solutions, LLC… Such conduct may result in the discontinuation of this service if is determined that I am at risk of injury to myself through the improper use of medication.

I will not hold Solace Healthcare Solutions, LLC or any of its employees responsible or liable of any injury or harm that may result from unauthorized tampering or accessing of the lock box containing medications.
Patient Signature:

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Patient Printed:

Patient Name:
MR#
MASSACHUSETTS HEALTH CARE PROXY FORM
I decline to provide a health care proxy at this moment. I understand that I may change my decision at any time and will contact the agency to provide this information . You Initial blanks
I blanks (the principal), residing at blank County, Massachusetts, pursuant to Massachusetts General Laws Chapter 201D, appoint the following person to be my Health Care Agent:
Name:
Phone #:
Address:
City/State/Zip:
If my Health Care Agent named above is not available, I name as an alternate Health Care Agent: Name:   First Name   Last Name
Phone #:   Area Code   Phone Number
Address:   Street Address   Address Line 2   City   State   Zip
I give my Health Care Agent authority to make all health care decisions on my behalf if I become incapable of making such decisions for myself, including but not limited to decisions concerning initiation, continuing, withdrawing or refusing any life-prolonging care, treatment, service or procedure, EXCEPT (here list the limitations, IF ANY, you wish to place on your Agent’s authority):
My Health Care Agent shall make health care decisions for me in accordance with my Health Care Agent’s assessment of my wishes, including my religious and moral beliefs. If my wishes are unknown, my Health Care Agent shall make such decisions for me only in accordance with my Health Care Agent’s assessment of my
best interests. My Agent may obtain any and all medical information, including confidential medical information, as I would be entitled to receive. Photocopies of this Health Care Proxy shall have the same force and effect as the original and may be given to other health care providers. My Health Care Agent’s authority to
act on my behalf shall exist only for the period during which my attending physician determines that I lack capacity to make or communicate health care decisions for myself.
I sign this Health Care Proxy on Date in the presence of two witnesses
Patient Signature:

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(If the Principal cannot sign) The principal is unable to sign and at the direction of the principal I have signed his/her name in his/her presence and in the presence of two witnesses. First Name Last Name
Street Address Address Line 2 City State Zip

Patient Name:
MR#
We, the undersigned witnesses, each declare in the presence of the principal that neither of us has been named as Health Care Agent or alternate Health Care Agent in this Health Care Proxy, and we further declare that the principal signed this instrument as his/her Health Care Proxy, or directed its execution, in the presence of each of us, that each of us signs this Health Care Proxy as witness in the presence of the principal, and that to the best of our knowledge he/she is eighteen (18) years of age or over, of sound mind, and under no constraint or undue influence.
Witness: blanks . Printed Name First Name Last Name
Address: Street Address Address Line 2 City State Zip
Witness: blanks . Printed Name First Name Last Name
Address: Street Address Address Line 2 City State Zip
STATEMENT OF HEALTH CARE AGENT (OPTIONAL) Health Care Agent:
I have been named by (the “principal”) as the principal’s Health Care Agent by his or her Health Care Proxy and I hereby accept this appointment. The principal has communicated to me his/her health care wishes at a time of possible incapacity, and I will try to give effect to the principal’s wishes. I am not an operator, administrator or employee of a hospital, nursing home, rest home, Soldiers Home or other health facility where the principal is presently a patient or resident or has applied for admission; or if I am such a person, I am also related to the principal by blood, marriage or adoption.
Signature of Health Care Agent:

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Date:

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Date
STATEMENT OF ALTERNATE HEALTH CARE AGENT (OPTIONAL) Alternate:
I have been named by (the “principal”) as the principal’s Alternate Health Care Agent by his or her Health Care Proxy and I hereby accept this appointment. The principal has communicated to me his/her health care wishes at a time of possible incapacity, and I will try to give effect to the principal’s wishes. I am not an operator, administrator or employee of a hospital, nursing home, rest home, Soldiers Home or other health facility where the principal is presently a patient or resident or has applied for admission; or if I am such a person, I am also related to the principal by blood, marriage or adoption.
Signature of Alternate Health Care Agent:

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Date:

MonthDayYear
Date

Patient Name:
MR#
Advance Beneficiary Notice of Noncoverage (ABN)
NOTE: If Medicare doesn’t pay for D. Services below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. Date* below.

E. Reason Medicare May Not Pay:

F. Estimated Cost

o Skilled Nursing Care

o Physical Therapists

o Occupational Therapists

o Speech Pathologists

o Medical Social worker

o Home health Aides

Homebound by medicare definition of the term. You are required ongoing contineous services not intermitted care

Ø Skilled Nursing Care $200

Ø LPN -$95

Ø Physical Therapists $200

Ø Occupational Therapists $200

Ø Speech Pathologists $200

Ø Medical Social worker $200

Ø Home health Aides $65

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the D. listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
If You Choose D

Skilled Nursing CarePhysical TherapistsOccupational TherapistsSpeech PathologistsMedical Social workerHome health Aides
G. OPTIONS: Check only one box. We cannot choose a box for you.*

OPTION 1. I want the {type} Services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.OPTION 2. I want the {type} listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.OPTION 3. I don’t want the {type}. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: Brockton Home Health Care will bill your secondary insurance
H. Additional Information: Solace Healthcare Solutions, LLC will bill your secondary insurance if your primary insurance refuses to pay the above services.

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.
I. Patient Signature:*

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J. Date:*

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Date
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Patient Name:
MR#
Patient Authorization Form
Name (Last, First): First Name* Last Name*
Address: Street Address Address Line 2 City State Zip Phone:
Payor Information
Primary insurance to be billed for your services is:
MEDICARE (expected amount payor will not pay      )
MEDICAID/MASSHEALTH (expected amount payor will not pay      )
INSURANCE (expected amount payor will not pay      )
Insurance company will pay   *  % of our charges and your portion is      % or $         per hour/per visit/ per day.
There is an out of pocket expense of $      and a deductible of$ The
insurance company will pay (      _of visits)
Service Order
I hereby authorize  QAZ Home Care agency, LLC   to provide the following services with identified frequencies: Aide
RN
RN    LPN   PT    MSW    ST    OT
Other (Please specify):
The billing rate for the above service checked is o per hour, o per day, o per visit
Or   Number   _____% of the agreed insurance arrangement as determined by your policy. My signature on this document indicates permission for Solace Healthcare Solutions, LLC to bill my insurance carrier for my homecare services as provided by my policy. I agree to pay any co-pay or non-covered amount over and above what my insurance covers.
Terms of service
The signature below acknowledges my/our acceptance of the following. Full financial responsibility for service(s) rendered to the above-named person. Payment is to be made payable to QAZ home Care Services. Have right to request for all visits invoiced to your insurance company. That I have not been coerced or forced to sign this document.
Signature of patient*

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Date*

MonthDayYear
Date
Signature of patient representative

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Date

MonthDayYear
Date
Should be Empty:

Solace Healthcare Solutions, LLC

Admission Package

Attention

Medicaid ID Card

CLARIFICATION OF THE HOMEBOUND DEFINITION UNDER THE MEDICARE HOME HEALTH BENEFIT

CONSENT & VERIFICATION OF RECEIPT OF INFORMATION

HIPAA:

Emergency Preparedness / Risk / Disaster

PATIENT DISASTER CODE

RISK LEVEL

POWER CODE

LOCK BOX USE AGREEMENT TO MANAGE MEDICATION COMPLIEANCE

MASSACHUSETTS HEALTH CARE PROXY FORM

Advance Beneficiary Notice of Noncoverage (ABN)

o Skilled Nursing Care

o Physical Therapists

o Occupational Therapists

o Speech Pathologists

o Medical Social worker

o Home health Aides

Ø Skilled Nursing Care $200

Ø LPN -$95

Ø Physical Therapists $200

Ø Occupational Therapists $200

Ø Speech Pathologists $200

Ø Medical Social worker $200

Ø Home health Aides $65

Patient Authorization Form

Payor Information

Service Order