Home Health Admission Consents

Home Health Consents & Admission Documents

All Care Home Health
Please Select One*

I am a patient's POA or Designated RepresentativeI am an All Care employee with a patient's POA or Designated RepresentativeI am an All Care employee with a self signing patient

Electronic Signature Consent and Disclosure
By accepting this disclosure, you are consenting: (i) to execute documents with All Care Health Solutions using e-signature; (ii) to exchange documents with All Care Health Solutions electronically. If you do not consent, All Care Health Solutions will provide an alternative method of document execution.
Additionally, by selecting “Accept” you are agreeing:
- That your use of a keypad, mouse, touchscreen, or other electronic device to select an item, button, icon or similar action, or to otherwise provide All Care Health Solutions with your assent during the document transaction (the “e-Signature”) constitutes your signature and acceptance of the content of the documents.
- That your e-Signature is the legal equivalent of your manual signature on the agreement.
- That your e-signature will be witnessed and verified by a member of All Care Health Solutions staff, and as such will require no certification authority or other third-party verification to validate your e-Signature, and the lack of such certification or third-party verification does not affect the enforceability of your e-Signature.
- That you represent that you are authorized to enter into the agreement for the patient, or yourself, if applicable.
- To conduct business with All Care Health Solutions via electronic documents.
- That All Care Health Solutions will provide a non-electronic copy of all records if you decline to consent the usage of electronic signature and records, upon request.
Electronic Signature Consent and Disclosure*

I ACCEPT
If Patient Declines the Electronic Signature Consent and Disclosure; Please complete paper copy of Admission Packet and deliver to All Care office.

This Page To Be Completed By All Care Admitting Staff
I agree, as an All Care Employee, that I will follow the policy set forth by All Care Health Solutions regarding Electronic Signatures and will have the Patient or Patient Representative sign and initial all required signature/initial fields*

yes
I agree, as an All Care Employee, that I will provide a paper copy of the full (blank) admission packet to the Patient or Patient Representative at the time of completing this form. I will also go through the admission packet with the Patient/Representative while completing this form.*

Yes
All Care Staff First Name*
All Care Staff Last Name*
All Care Staff Title (RN, PT, DPT, OT, LMSW, etc)*
All Care Staff Email Address
If you would like an emailed copy of admission packet
Please Verify Email Address is Correct. Email Notification will be sent. Confirm your email address ends with @myallcare.net
NOTE: DO NOT ROTATE PHONE

For Best Signature Results, Do not rotate phone. Pinch to Zoom if needed. Zooming in will slow down signature speed, so sign slowly.
ALL CARE STAFF SIGNATURE*

Clear
Please ensure staff signature is visible in the box above before clicking Next
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Patient Basic Information
Patient First Name*
Patient Last Name*
Patient Middle Name
Other Names Used By Client (Blank if None)
Patient Date of Birth*

MonthDayYear
Date
Patient Sex*

MaleFemale
Has the Patient Signed a Durable Power Of Attorney for Health Care?*

YesNo
Has the Patient Signed a Living Will or Directive to Physicians?*

YesNo

Patients Power of Attorney/Representative Contact Information
Full Name (POA or Representative)*
Relationship to Patient*
Email Address (POA or Representative)*
example@example.com
Phone Number (POA or Representative*
Please enter a valid phone number.
Address, City, State, Zip (POA or Representative)*
Reason patient is unable to sign:*
Do you have Power of Attorney Documents you would like to upload here?*

YesNo
File Upload - Size Restricted to 4mb. If file is too large, please email to admits@myallcare.net

Cancelof
Page Intentionally Blank, please click next

Patient Portal Setup

CMS requires that patient care documents are delivered to the patient, or a representative that the patient designates. This can be a family member, Power of Attorney, or a friend. Please gather an email address, or a name and phone number for this person and input it below. This will speed the process of delivering documents such as a signed copy of this admission packet, visit schedule, orders and communication notes, and progress summary reports.
Patient or Representative Email/Name and PhoneNumber*

Admission Consent
Frequencies - Check all that apply - Admitting Discipline Frequency Order Must Match Admission Packet

NursePTOTSLPSWAIDEOther
Nursing Frequency - (If Unknown Please Write EVAL)*
DO NOT ABBREVIATE, PLEASE WRITE OUT FULL FREQUENCY
PT Frequency - (If Unknown Please Write EVAL)*
DO NOT ABBREVIATE, PLEASE WRITE OUT FULL FREQUENCY
OT Frequency - (If Unknown Please Write EVAL)*
DO NOT ABBREVIATE, PLEASE WRITE OUT FULL FREQUENCY
SLP Frequency - (If Unknown Please Write EVAL)*
DO NOT ABBREVIATE, PLEASE WRITE OUT FULL FREQUENCY
SW Frequency - (If Unknown Please Write EVAL)*
DO NOT ABBREVIATE, PLEASE WRITE OUT FULL FREQUENCY
Aide Frequency - (If Unknown Please Write EVAL)*
DO NOT ABBREVIATE, PLEASE WRITE OUT FULL FREQUENCY
Other Frequency - (If Unknown Please Write EVAL)*
DO NOT ABBREVIATE, PLEASE WRITE OUT FULL FREQUENCY

Read More About Consents, Rights, Responsibilities and Release of Information
Consent for Care

I hereby give my voluntary consent for All Care Health Solutions to provide care and treatment to me in my home as directed by my physician.

Patient Rights and Responsibilities

I acknowledge that I have been fully informed of my rights and responsibilities as a patient. I understand that I and/or my family/caregiver will be responsible for my care in the absence of the home care staff.

Release of Information

I authorize All Care Health Solutions to use and disclose protected health information about me for the purposes of treatment, payment, and health care operations. The agency may release information to or receive information from physicians, hospitals, other health care providers, family members and others involved in my plan of care, assisted living facilities, third party payers, and regulatory agencies as necessary for my care or to process my claims.

Consent to Photograph

I hereby consent to allow the agency to take my photograph for identification purposes and/or for documenting my medical condition.

Medicare/Pinnacle Quality Survey
All Care Health Solutions is participating in a national survey to provide the United States Department of Health and Human Services with information about the quality of health care delivered to people in their homes. You may be selected to take part in this important telephone interview. We have partnered with Pinnacle Quality Insight to contact our patients via telephone to complete this interview. Phone calls from Pinnacle Quality Insight will appear on your caller ID as being from a toll-free area code.

The number that will appear on your caller ID is 1-877-308-3844.

This will help you know when Pinnacle might be calling, so that you will feel safe to answer. Please keep this in mind so that you do not miss this survey opportunity.

The interview results will improve the quality of care people receive and help people make more informed decisions when choosing a health care provider. Results will be publicly reported on the Internet at Home Health Compare at http://www.medicare.gov/. The interviewer will ask your opinions about the home health care you received. We hope that you will take a few minutes to go through this important call.

If you need help completing the interview, please ask a family member or friend to help you. It is important that your answers reflect your own opinions about the home health care you received, so please do not ask anyone from our agency for help completing the survey.

Your participation in this survey is totally voluntary. It will not have any effect on your health care or benefits. All information will be held in confidence and is protected by the Privacy Act. Your name will not be attached to the publicized results.

If you have any questions about the survey, please contact Pinnacle Quality Insight at 1-877-308-3844.

Thank you in advance for your participation.
We Recommend Adding 1-877-308-3844 To Your Phone Contacts List In Advance.

Medicare Homebound Requirements
MEDICARE CONSIDERS YOU HOMEBOUND IF:
- You experience a normal inability to leave your home;
- It requires considerable and taxing effort to leave your home;
- Absences from home are infrequent, of short duration, or are for medical treatment;
A YES ANSWER TO ANY OF THE FOLLOWING QUESTIONS ESTABLISHES HOMEBOUND STATUS

PLEASE CHECK ALL THAT APPLY
Do you have a condition that restricts yourability to leave home except with the aid ofsupportive devices and assistance of anotherperson?*

YESNO
Are absences from the home infrequent, of short duration and usually to receivemedical care not available in the home?*

YESNO
Are there a combination of factors such as architectural barriers, stairs, cognitive or safety issues that result in an inability to leave home without assistance? (Psychiatric problems, cognitive deficits blindness, organic brain disorder, Alzheimer’s disease, etc. could qualify)*

YESNO
Is leaving home mentally contraindicated?*

YESNO

Home Health Consents & Admission Documents

Electronic Signature Consent and Disclosure

If Patient Declines the Electronic Signature Consent and Disclosure; Please complete paper copy of Admission Packet and deliver to All Care office.

This Page To Be Completed By All Care Admitting Staff

Please Verify Email Address is Correct. Email Notification will be sent. Confirm your email address ends with @myallcare.net

NOTE: DO NOT ROTATE PHONE

Please ensure staff signature is visible in the box above before clicking Next

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Patient Basic Information

Patients Power of Attorney/Representative Contact Information

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Patient Portal Setup

Medicare Replacement Products

Admission Consent

Medicare/Pinnacle Quality Survey

We Recommend Adding 1-877-308-3844 To Your Phone Contacts List In Advance.

Liability for Payment

Medicare Homebound Requirements

Authorizations to Release Information

For Payment and Reimbursement Purposes

Authorization for Release of Medical Information

Financial Contact Release of Medical Information

TB SCREENING UPON ADMISSION

MEDICARE SECONDARY PAYER WORKSHEET

PRIMARY PAYER INFORMATION

Local and Medical Suppliers

Statement Affirmations

ELECTRONIC SIGNATURE - THE FOLLOWING TO BE COMPLETED BY PATIENT or POA/Representative ONLY

NOTE: DO NOT ROTATE PHONE

Please ensure signature and initials are visible in signature boxes before submitting form.