Consents_HSP_CE

Hospice Consents and Election of Benefits

All Care Hospice
Please Select One:*

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

This Page To Be Completed By All Care Admitting Staff Only
I agree, as an All Care Employee, that I will follow the policy set forth by All Care 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, MSW, etc)*
All Care Staff Email Address*
NOTE: DO NOT ROTATE PHONE

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All Care STAFF SIGNATURE*

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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.
Electronic Signature Consent and Disclosure*

I ACCEPT

Patient Basic Information
Patient First Name*
Patient Last Name*
Patient Middle Name
Patient Date of Birth*

MonthDayYear
Date
Patient Sex*

MaleFemale
Advanced Directives (Page C19)

I have been made aware of my right to make health care decisions for myself. I am also aware that I may express my wishes in a document called an Advance Directive so that my wishes may be known when I am unable to speak for myself. Please complete the following questions:
Has the Patient Signed a Durable Power Of Attorney for Health Care?*

YesNo
Has the Patient Signed a Living Will?*

YesNo
Has the Patient Signed a POST Form? (Idaho Physician Orders For Life-Sustaining Treatment)*

YesNo

Patients Power of Attorney/Representative Contact Information
Full Name (POA or Representative)*
Relationship to Patient*
Email Address (POA or Representative)*
Phone Number (POA or Representative*
Please enter a valid phone number.
Address, City, State, Zip (POA or Representative)*
Reason Patient is unable to sign:*
Enter specific reason patient cannot sign (e.g.): Unconscious, Advanced dementia, Severe Weakness, etc.
Do you have Power of Attorney Documents you would like to upload here?*

YesNo
File Upload

Click the Browse Files or Drag and Drop Files into Box
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Consent for Primary Caregiver
I agree to accept the role of primary caregiver.*

Yes
- 1. I understand the goal of hospice is not to cure the terminal illness but to provide symptom relief and supportive care in this final phase of life.
  
  2. I understand the hospice interdisciplinary team will provide education, training, and support in the management of the patient's physical, emotional, psychosocial, and spiritual needs.
  
  3. I understand the hospice staff will provide emotional, psychosocial, and spiritual support to help me cope with my caregiver responsibilities, the eventual patient's death, and my bereavement.
  
  4. I understand that in my role as a primary caregiver, I will be responsible for meeting or arranging for the patient's 24 hours a day care needs. I will arrange for care in my absence.
  
  5. I understand the hospice medical record will contain information about me. Every effort will be made to keep this information confidential. I authorize this information to be released to the attending physician and other appropriate healthcare providers for the patient's care. I also authorize the release of this information, as needed, to process insurance claims.
  
  6. I understand hospice services are primarily provided on a prearranged, appointment basis, but crisis or consultation assistance with hospice is available 24 hours a day, 7 days a week. I will consult hospice in case of any emergency.
  
  7. I understand to receive full benefits of hospice care it is important for me and the patient to make our needs and concerns known to the hospice interdisciplinary team and to participate in the planning for care.
  
  8. I understand I may choose to change my mind about this method of care and withdraw from this primary caregiver agreement. However, I agree not to do so without giving advance notice to the patient and hospice, so another primary caregiver can be arranged for.
  
  9. I have received the Patient/Family Orientation for Hospice Care Packet. At this time, I believe I understand the responsibility of being primary caregiver, the nature of the patient's illness, and the goal of hospice care. My questions about the hospice program have been answered to my satisfaction by the hospice staff.

Additional Family/Friend Contacts (Not Required)

Page C15
Please select the number of additional contacts you would like to add (if any)*
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address

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 enter 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.
Patient or Representative Email. If Unknown Please Provide Name and Phone Number so that we may call and ask for this information.*

Hospice Election of Benefits (Pages C1-C4)
Hospice Election of Benefits*

I choose to elect the Medicare hospice benefit and receive Hospice services from All Care Hospice.
Right to Choose an Attending Physician (Page C1)
I understand that I have a right to choose my attending physician to oversee my care. My attending physician will work in collaboration with the hospice agency to provide care related to my terminal illness and related conditions.*

I do not wish to choose and attending physicianI acknowledge that my choice for an attending physician is Dr Jason Ludwig, DOI acknowledge that my attending physician is VA Physician Caitlin Mohr, M.D.I acknowledge that my attending physician is VA Physician Megan Dunay, M.D.
All Care Hospice Physician: Dr. Jason Ludwig, D.O. NPI: 1144258534

Office Address: 4740 N Penngrove Way, #100. Meridian, ID 83646

Veterans Affiars Hospice Physicians:

VA Physician: Caitlin Mohr, M.D. NPI: 1346535952

Office Address: 500 W Fort St. Boise, ID 83702

VA Physician: Megan Dunay, M.D. NPI: 1801107974

Office Address: 500 W Fort St. Boise, ID 83702

I acknowledge and understand the above, and authorize Medicare hospice coverage to be provided by All Care Hospice effective as early as today's date.
Patient Notification of Hospice Non-Covered Items, Services, and Drugs (Page C2)

I elect to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”I decline to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”
Note: The hospice makes the decision as to whether or not conditions, items, services, and drugs are related for each beneficiary. This addendum should be shared with other health care providers from which you seek item, services, or drugs, unrelated to your terminal illness and related conditions to assist in making treatment decisions.

Hospice must furnish this addendum within 5 days if requested at the time of hospice election and within 72 hours if requested during the course of hospice care.
- I acknowledge that I have been given a full explanation and have an understanding of the purpose of hospice care. Hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions and such care will not be directed toward cure. The focus of hospice care is to provide comfort and support to both me and my family/caregivers.
- I understand that by electing hospice care under the Medicare Hospice Benefit, I am acknowledging that I understand the palliative rather than curative nature of hospice care, as it relates to my terminal illness and related conditions. I understand that by electing hospice care under the Medicare Hospice Benefit, I am waiving (give up) all rights to Medicare payments for services related to my terminal illness and related conditions and I understand that while this election is in force, Medicare will make payments for care related to my terminal illness and related conditions only to the designated hospice and attending physician that I have selected. I understand that services not related to my terminal illness or related conditions will continue to be eligible for coverage by Medicare; however, I also understand that services unrelated to my terminal illness and related conditions are exceptional and unusual and hospice should cover all care related to my terminal illness and related conditions needed under the hospice election.
- • As a Medicare beneficiary who elects to receive hospice care, you have the right to request at any time, in writing, the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum that lists conditions, items, services, and drugs that the hospice has determined to be unrelated to your terminal illness and related conditions, and that will not be covered by the hospice.
  • If I request this form within the first 5 days of the election start date, the hospice must furnish the written addendum within 5 days of the request date. If I request this form during the course of hospice care (that is, after the first 5 days of the hospice election start date), the hospice must furnish this written addendum
  within 3 days of the request date.
  
  Beneficiary and Family Centered Care Quality Improvement Organization Contact Information
  
  As a Medicare hospice beneficiary, you have the right to contact the Beneficiary and Family-Centered Care Quality Organization (BFCC-QIO) to request Immediate Advocacy if you disagree with any of the hospice’s determinations. The BFCC-QIO that services your area is:
  
  Acentra Health - 888-317-0891
  
  Beneficiary and Family Centered Care Quality Improvement Organizations help file quality of care complaints as well as immediate advocacy services to quickly resolve medical concerns. For information about the availability of auxiliary aids and services please visit:
  
  www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html
  
  This website has been designed to comply with Section 508 of the U.S. Rehabilitation Act.
- As a Medicare beneficiary you have the right to appeal the decision of the hospice agency on items not being covered because the hospice has determined they are unrelated to the individual’s terminal illness and related conditions. You have the right to contact the Medicare Beneficiary and Family Centered-Quality Improvement Organization (BFCC-QIO) for immediate assistance. Visit this website to find the BFCC-QIO for your area.
  
  call 1-800-MEIDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
- The purpose of this addendum is to notify beneficiary (or representative), in writing, of those conditions, items, services, and drugs the hospice will not be covering because the hospice has determined they are unrelated to the individual’s terminal illness and related conditions. I acknowledge that I have been given a full explanation and have an understanding of the list of items, services and drugs not related to my terminal illness and related conditions not being covered by hospice. Signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not necessarily agreement with the hospice’s determinations.

Hospice Services Disclosure Form (Page C5)

Your signature on the affirmations page acknowledges you have received and fully understand All Care Hospice Services Disclosure Form.
Medicare Hospice Levels of Care*

ROUTINE HOME CARE is provided in a patient's residence or a nursing facility if they reside thereCONTINUOUS CARE is used to provide intensive care for short periods of time to manage a crisis situation. At least 8 hours of direct one on one care must be required during a 24 hour period, and at least half of that care must be provided by a licensed nurseINPATIENT CARE for the control of acute pain or symptoms that cannot be adequately managed in the home, short-term care is provided in a hospital or skilled nursing facilityRESPITE CARE is provided in a hospital or skilled nursing home to allow the patient's primary care giver a rest. Up to 5 days of respite care are allowed at a time.
- Required Services Covered by the Medicare Hospice Benefit
  
  All of the following services are required and covered if they are needed to palliate the symptoms of a terminal diagnosis and are included in the patient's Plan of Care.
  - Medicines, medical supplies, and durable medical equipment (hospital bed, walker, etc.)
  - Laboratory services
  - X-ray and radiation therapy
  - Emergency services
  - Ambulance and transport services
  - Short-term inpatient stays in a hospice facility, hospital, or skilled care facility for management of acute symptoms
  - Short-term continuous nursing care in the home for crisis care of acute symptoms that can be managed at home with extra support from the hospice team.
  - Five-day inpatient respite periods when caretakers require a break from care giving responsibilities
  - Bereavement support and counseling services
  - Use of an interdisciplinary team
    
    Medical supervision and physician services
    
    Individual case management and coordination of care by a registered nurse
    
    Intermittent nursing visits
    
    Social work services
    
    Pastoral counseling and spiritual support provided or coordinated by a hospice chaplain
    
    Home health aide and homemaker services
    
    Volunteer services
    
    Dietary Counseling and physical, occupational, speech, and respiratory therapy services as appropriate
  Special Services
  
  I understand that if I need hospitalization or special services not provided by hospice, I or my legal representative must make arrangements for these services. The hospice shall in no way be responsible for failure to provide the same and is hereby released from any liability arising from the fact that I am not provided with such additional care.
  
  I have read and understood the services provided by All Care Hospice and the four levels of care as outlined above. I have also received a copy of this form.

911/Emergency Services Notice to Protect You (Page C6)
It is an honor to care for you, or your loved one during this difficult time. We would like to take a moment to explain the Medicare/Medicaid hospice benefit and what it covers in terms of emergency/ urgent care services.

Once a person chooses to receive hospice care, they enable the hospice benefit election. Part of that benefit is that a patient chooses not to receive curative treatment for their terminal diagnosis. A patient can still call 911 or go to the emergency room for injuries/illnesses that are not related to their terminal diagnosis. However, the hospice agency must be aware of all treatments and services the patient is going to receive prior to receiving care. Hospice can provide most services and treatments, so contact hospice prior to calling 911.

If you or your loved one wish to enable 911 or emergency services, the hospice agency must first obtain a revocation notice from you.

By signing below, you acknowledge that you must sign a revocation notice prior to obtaining any other medical interventions such as emergency services or calling 911. This will enable you to use those services and they will get billed to your insurance instead of you. In the event that you don't sign the revocation form before seeking treatment, the hospital and/or emergency services can bill you for the services instead of your insurance.

Your signature on the affirmations page acknowledges you have received and fully understand All Care Hospice's explanation of the Medicare/Medicaid Hospice Benefit as it applies to emergency and urgent care services.
Patient Document Delivery

In order to share medical information with you, All Care will need to know the best way to do so.*** Please check ONE of the boxes below to let us know which delivery method you prefer***
** Email is preferred as we can setup a patient portal to access documents and rapidly upload these documents for you**
Patient Document Delivery

EmailMailDeliver to Patients Home
Email Address*
Address or Facility Name*

Authorization to Release Information for Payment and Reimbursement Purposes (Page C7)
I have been informed that All Care Hospice offers hospice care to those who have a terminal illness. I understand that hospice is palliative rather than curative in its goals, and that hospice emphasizes the relief of symptoms, and or emotional/spiritual distress that may accompany my illness. Care is physician directed, through my attending physician and the medical director for All Care Hospice. Hospice care may involve skilled nursing care, volunteer companions, certified hospice aide care, emotional and spiritual care, social workers and inpatient care.

In consideration of the mutual promises and obligations related to treatment to be rendered to the patient/family by All Care Hospice, it is agreed as follows:

Treatment: Consent is given for examinations and treatments as prescribed by the patient’s physician (or All Care Hospice physician) rendered by All Care Hospice licensed nurses, physical therapists, occupational therapists, speech pathologists, registered dietitians, clergy, home health aides, hospice volunteers, social workers and their clinical supervisors.

Patient Information Authorization & Release: By signing this consent, you authorize All Care Hospice to use and/or disclose your health information for treatment, payment, or health care operations. Consent is also given for the release of information to All Care Hospice by any insurer of the patient and all other agencies or medical facilities from who the undersigned has received medical or social services. You have the right not to sign this consent. However, if you refuse to sign this consent, we have the right to refuse to treat you.
1. Along with this consent form, we have also provided you a copy of our Notice of Privacy Practices, which details how we may use & disclose your health information. You have the right to review this notice before signing this consent. We may amend the notice from time to time.
2. You have the right to request that we restrict how we use and/or disclose your protected health information for the purpose of providing treatment, obtaining payment for our services, and/or conducting health care operations. Such requests must be made in writing. Please note that we are not required to agree to any restriction you may request. If, however, we decide to agree to a restriction you have requested, we must restrict our use and/or disclosure of your health information in the manner described in your request.
3. You have the right to revoke this consent at any time. Your revocation of this consent must be in writing. If you wish to revoke this consent, please contact our office. Note that our revocation of this consent will not be effective for disclosures we have already made based on prior consent. We also have the right to refuse to provide further treatment if you revoke this consent.
4. You have a right to receive a copy of this consent form after you sign it.
5. This consent is effective unless and until you revoke it in writing.
Termination: Except for Medicare-eligible hospice patients, All Care Hospice, upon due notice of no less than 30 days, may terminate services for lack of payment for its services. In addition, All Care Hospice may terminate services, when in its sole medical judgment determines there is no longer any reasonable expectation that it can meet the patients' and/or family’s needs.

Authorizations for Release of Medical Information (Page C8)

This authorization will remain in effect a maximum of six months from the date of signature and may be canceled 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. A photocopy of this authorization will be treated in the same manner as the original.
Patient/POA/Representative Authorizes Release of Medical Information for the purpose of Coordination of Care.*

YesNo
- - History and Physical Exam
  - Progress Notes
  - Clinical Summary
  - Physician's Notes
  - Consultation Reports
  - Laboratory Reports
  - Operative Reports
  - Nurse's Notes
  - Pathology Reports
  - Outpatient Information
  - X-Ray Reports
  - Other (Specify):

Pinnacle Quality Insights Survey Notice (Page C10)
All Care Hospice 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 you 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 1-888-444-9961.

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 interviewer will ask for your opinions about the hospice care your loved one received. We hope that you will take a few minutes to go through this important call. The survey is designed to measure caregiver's perspectives on hospice care for public reporting. The data collected from the survey will be provided to consumers to help them make informed choices when selecting a hospice. It will also be used to help improve the quality of care provided by hospices. Your participation is important.

It is important that your answers reflect your own opinions about the Hospice care your loved one received, so please do not ask anyone from this Hospice Agency for help completing the survey.

All information you give in this survey 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 1-888-444-9961.

Thank you in advance for your participation.
We Recommend Adding 1-888-444-9961 To Your Phone Contact List

Oxygen Use Waiver - Page C11
As our patient, we want to make sure that you get the education, tools, and training you need to remain safely in your home. If you use oxygen, the following conditions can put you at risk. Please ask questions or state your concerns should you have any at any time.*

Being a smoker and having oxygen in your homeSmoking while using oxygenOthers around you smoke while you are using oxygenThe presence of candles, fireplace, wood burning stove, oven, and or barbequeN/A
- This is a very serious concern as your personal well-being and safety are of the utmost importance to us. The purpose of this letter is to stress how important it is to follow All Care Hospice's well-defined safety precautions.
  
  The All Care Hospice Patient/Family Orientation for Hospice Care binder refers to fire safety and oxygen use precautions. Oxygen greatly enhances combustion and is therefore a primary safety concern while you are on oxygen. Please see Section 6: Safety in the Patient/Family Orientation for Hospice Care binder for further information. Fire Safety/Burn Precautions starts on page 24 and continues through page 25. Specific Oxygen Safety is on page 28.
  
  Your signature on the affirmations page acknowledges you have received and fully understand All Care Hospice's Oxygen Safety and Fire Precaution Recommendations. Your signature also indicates you will follow the recommendations as set forth in the Patient/Family Orientation Binder for Hospice Care. Failure to do so may lead to serious injury, up to and including death. The patient assumes responsibility for any injury incurred by failure to follow this policy.

Hospice Benefit Authorization (Page C18)

Medicare Benefit Recipients: The patient understands that application for payment under Title XVIII of the Social Security Act may be made and that information must be provided by the patient in order to receive such payment. The patient hereby certifies that the information given in applying for payment under Title XVIII of the Social Security Act is correct. The patient hereby requests payment of authorized Medicare benefits are to be made on the patient's behalf.
1. All Care Hospice will receive payment for my care, relating to my terminal illness. Medicare will continue to make payment to my attending physician for services if my physician is neither a hospice employee nor receiving payments from All Care Hospice. If my physician is a hospice employee, All Care Hospice will bill Medicare for visits to my physician. I understand that I have the right to seek treatment or therapy for any condition unrelated to my terminal illness in the normal manner. Any such care is not reimbursed by All Care Hospice.*

Yes (Also Inserts Initials)
2. I accept Medicare benefits related to my terminal illness while enrolled in the Medicare Hospice program. I understand that I must have prior approval from hospice before ordering or receiving treatments, supplies, equipment, or any other service related to my terminal illness. I understand that if I fail to get preauthorization from All Care Hospice for any services, treatments, supplies, equipment, etc., related to my illness, I may be financially responsible for charges incurred.*

Yes (Also Inserts Initials)
3. The Medicare hospice program is divided into benefit periods consisting of two 90-day periods and unlimited 60-day periods. I must use the benefits periods in the above order. I may discontinue hospice care at any time by completing a revocation statement. If I revoke during a benefit period, I lose the remaining days in that benefit period. I have the option of changing to another hospice once per benefit period.*

Yes (Also Inserts Initials)
4. I acknowledge that I have been given a copy of the Patient's Rights and Responsibilities and Notice of Hospice Privacy Practices.*

Yes (Also Inserts Initials)
5. As a Medicare recipient, I understand the above and authorize hospice Medicare services from CaringEdge Hospice by signing below.*

Yes (Also Inserts Initials)
Certification: The undersigned hereby certifies that he or she has read the foregoing, received a copy thereof, and is the patient or is the duly authorized patient's agent/representative authorized by the patient to execute the above and accept its terms.

Payment Responsibilities and Additional Consents (Page C19)
- The patient and/or the patient's authorized agent have full responsibility for the payment of all fees and charges in accordance with All Care Hospice's fee schedule. It is understood that for hospice patients, All Care Hospice assumes financial responsibility for medications and/or durable medical equipment and medical supplies related to the terminal illness. The patient and/or patient's agent assumes financial responsibility for all other unauthorized charges. All Care Hospice, in accordance with this agreement, shall assist the patient in obtaining financial assistance from third-party payers, such as Medicare, Medicaid and private insurers.
  
  Rates: Should a patient choose to receive care from All Care Hospice without having Medicare, Medicaid, other private insurance, or third party payer source, the following rates will apply:
  - Routine Home Care: $166/Day
  - Inpatient Care: $704/Day
  - Continuous Care: $48/Hour
  - Respite Care: $171/Day
  If your ability to pay after you are on hospice, you will not be removed from hospice care due to inability to pay.
- Medicare/Medicaid hospice care is a Medicare or Medicaid benefit. As such, patients can choose what hospice agency provides their hospice care. By signing, I confirm that I am aware that I have a choice over which agency provides my hospice care and I have chosen All Care Hospice of my own free will. If at any time I wish to discontinue care with All Care Hospice, I or my legal representative must contact All Care Hospice at (208)473-2717 to cancel.
- I hereby consent for the agency to record or film my care, treatment, and services and allow the agency to use the photographs/recordings for their internal use, for documenting my medical condition, or for insurance providers to document my condition for payment purposes.
- The Following services are available to you and will be determined upon admission and evaluation. If there is a change in any of these services or frequencies, they will be communicated to you.
  - Skilled Nursing
  - Hospice Aide
  - Social Worker
  - Spiritual Care
  - Volunteer Services
- All Care Hospice does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, publication in its programs, services, activities, or in employment. For further information about this policy, contact the All Care Hospice Administrator at (208) 473-2717.
  - Administratior: Gavin Manly, RN
  - Assistant Administrator: Jessica Meyers
  - Director of Nursing: Tara Anthony-Sharrad, RN

Hospice Consents and Election of Benefits

This Page To Be Completed By All Care Admitting Staff Only

NOTE: DO NOT ROTATE PHONE

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Electronic Signature Consent and Disclosure

Patient Basic Information

Advanced Directives (Page C19)

Patients Power of Attorney/Representative Contact Information

Consent for Primary Caregiver

Additional Family/Friend Contacts (Not Required)

Patient Portal Setup

Hospice Election of Benefits (Pages C1-C4)

Right to Choose an Attending Physician (Page C1)

Hospice Services Disclosure Form (Page C5)

911/Emergency Services Notice to Protect You (Page C6)

Patient Document Delivery

Authorization to Release Information for Payment and Reimbursement Purposes (Page C7)

Authorizations for Release of Medical Information (Page C8)

Pinnacle Quality Insights Survey Notice (Page C10)

We Recommend Adding 1-888-444-9961 To Your Phone Contact List

Oxygen Use Waiver - Page C11

TB Screening Upon Admission (Page C12)

Disaster Preparedness Plan (Pages C13-C14)

Insurance and Billing (Page C16)

Hospice Benefit Questions

MEDICARE SECONDARY PAYER WORKSHEET (Page C17)

PRIMARY PAYER INFORMATION

Hospice Benefit Authorization (Page C18)

Payment Responsibilities and Additional Consents (Page C19)

Statement Affirmations (Page C20)

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

NOTE: DO NOT ROTATE PHONE

Please Ensure Signature and Initials are Visible Before Submitting Form.