• Home Health Consents & Admission Documents

    All Care Health Solutions

  • Electronic Signature Consent and Disclosure

  • By accepting this disclosure, you are consenting: (i) to execute documents with All Care using e-signature; (ii) to exchange documents with All Care electronically. If you do not consent, All Care 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 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 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 via electronic documents.
    • That All Care will provide a non-electronic copy of all records if you decline to consent the usage of electronic signature and records, upon request.

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

    For Best Signature Results, Do not rotate phone. Pinch to Zoom if needed. Zooming in will slow down signature speed, so sign slowly.
  • Clear

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

  • Please Click Next... This page is intentionally left blank

  • Patient Basic Information

  •  / /

  • Patients Power of Attorney/Representative Contact Information

  • Format: (000) 000-0000.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Page Intentionally Blank, please click next

  • Patient Document Delivery

    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 select the preferred option 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.

  • Medicare Replacement Products

    If you have a Medicare HMO or Advantage Plan, You are responsible for any co-pays and/or co-insurance costs.

  • Admission Consent

    • Read More About Consents, Rights, Responsibilities and Release of Information 

    • Consent for Care

      I hereby give my voluntary consent for All Care 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 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.

  • Liability for Payment

    • Read More About Liability for Payment and HMO 

    • Liability for Payment

      I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act and/or from any third party payer is correct. I request that payment of authorized benefits from Medicare, Medicaid, or other responsible payers be made in my behalf to All Care Health Solutions.

      Health Maitnenance Organization (HMO)

      If I enroll in one, I will immediately notify All Care. If I have Medicare benefits, I understand that Medicare payments will be accepted as payment in full unless All Care notifies me in writing that the services will not be covered by Medicare. I understand that while I am under All Care's plan of care, All Care will coordinate all medically necessary therapy services and medical supplies for me. Should I arrange for these services or supplies on my own, I understand that Medicare will not reimburse me or my supplier, and I will be responsible for their cost. If I have other Insurance, I may be responsible for co-payments and any charges that my insurance will not cover. All Care will advise of any change in payments no later than thirty (30) days prior to change. Those costs will be itemized and explained to me on a separate Service Agreement.

      Patient Responsibility

      Patient responsibility is outlined on intake form per your individual insurance plan.

  • 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

  • Authorizations to Release Information

  • For Payment and Reimbursement Purposes

  • Authorization for Release of Medical Information

    This authorization will remain in effect from the date of signature and may be canceled by me in writing at any time. I understand that such cancellation may be harmful to proceedings requiring these records. I do not authorize re-release of this information to anyone.

  • Financial Contact Release of Medical Information

  • TB SCREENING UPON ADMISSION

  • MEDICARE SECONDARY PAYER WORKSHEET

  • PRIMARY PAYER INFORMATION

  • Local and Medical Suppliers

  • Format: (000) 000-0000.

  • Home Health Agency Choice

  •   Home Health Agencies Phone Number
    X All Care Health Solutions 208-473-2717
      Terrace Health Boise 208-506-7200
      First Choice Home Health and Hospice 208-322-4663
      Trinity Home Care 208-938-1760
      Visiting Angels 208-888-3611
      Havenwood Home Care 208-327-1011
      AAA Home Care 208-345-6123
      Interim Healthcare of Boise 208-938-9681
      Zions In Home Health Care 208-319-4587
      Infinity Care and Services LLC 208-639-0126
      Treasure Valley Home Care 208-713-9510
      A1 In Home Health 208-377-3113

  • Statement Affirmations

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

  • NOTE: DO NOT ROTATE PHONE

    For Best Signature Results, Do not rotate phone. If you need a larger box, pinch and zoom in to make the box larger. Zooming in will slow down signature speed, so sign slowly.
  • Clear
  • Clear
  •  / /

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

  • Should be Empty: