I understand that hospice is not to cure my disease, but rather to provide symptom control and comfort in dealing with my disease and is palliative in nature.
I understand all hospice services are administratively supervised by the Administrator and clinically supervised by the Supervising Nurse under the medical direction of the hospice Medical Director.
I understand it is my right to choose my attending physician who will direct my care, and I choose       to be my attending physician.
I understand the hospice services are covered and provided according to my individualized plan of care and may include the following:

• Physician Services
• Nursing Services
• Medical Social Services
• Spiritual Counseling Services
• Hospice Aide/Homemaker Services
• Continuous Care for medical crisis
• Dietitian/Nutritionist
• Volunteer Services
• Therapy Services (Physical, Occupational, Speech)
• Medications related to pain and symptom control
• Durable Medical Equipment and Medical Supplies
• Inpatient care for symptom management or respite care

I understand, by election of the Hospice Medicare or Medicaid benefit, that care and treatment for my hospice diagnosis must be facilitated through hospice.
The Effective date of election to the Medicare or Medicaid Benefit is      
I understand that I am electing the (1st, 2nd, 3rd, 4th, etc.)    certification period. 

Operating Hours/Contact Information

I elect   to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs"
Initials         Date   
(Hospice: Please provide the beneficiary with the addendum. Must be signed and dated accompanying the election Statement.) 

I decline to   receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs"
Initials         Date 

I have been given the opportunity to review, to ask questions, to discuss concerns regarding the information provided to my satisfaction. 

I,  , the undersigned patient/guardian for  , hereby requests that home health services be transferred from  to Redeemer Hospice.

I believe I will be better served by Redeemer Hospice
I wish to be served by Redeemer Hospice by a nurse/aide employed by Redeemer Hospice
Other (explain)            

Healthcare information relating to the following treatment, condition:
(All healthcare information)    

Other::        

Frequency of Contact:

With every visit by:     Nursing     SCC    MSW    
Once a week only by:     Nursing          
Only with changes in condition by:     Nursing     SCC    MSW    

Others who Hospice can communicate my Protected Health Information to, if present during visits: 

Name       Relationship       Ph#  
Name       Relationship       Ph#  
Name       Relationship       Ph#  

Do NOT communicate with the following my Protected Health Information:

Name       
Name       

I understand that I may revoke this authorization at any time by giving written notice to Hospice:

I, (patient/representative name)       
understand the Hospice Agency may need to take photographs solely for the purposes of providing medical information to the physician or others involved in my care, or to record in my medical record. I also understand the photograph(s) will be treated and handled in a confidential manner and I may request possession of the photographs or they be destroyed at any time.

I further hereby release the Hospice Agency and its personnel from any and all liability in the taking and use of these photographs. I also understand that these photographs may be submitted upon request to insurance companies, Medicare or Medicaid, and other payers of care. 

At the time of admission, I am able to make my own decisions and I do not currently need a primary caregiver. My plan for care, when the hospice team determines it is no longer safe for me to be alone, is as follows: 

Check one:

My primary caregiver will be (contact to review and complete lower section):

Name:   First Name   Last Name   

Address:       

Phone Number:Area Code   Phone Number   

Other plans :        

At time of admission, the patient has a primary caregiver:

Name:   First Name   Last Name   

Address:       

Phone Number:Area Code   Phone Number