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.
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.
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.
4. I acknowledge that I have been given a copy of the Patient's Rights and Responsibilities and Notice of Hospice Privacy Practices.
5. As a Medicare recipient, I understand the above and authorize hospice Medicare services from CaringEdge Hospice by signing below.
Statement Affirmations - Page C20:
1. I have read the Name of Beneficiary of Health Insurance form and its contents, and furthermore acknowledge that if I have a Medicare HMO or Advantage Plan, I am responsible for any co-pays and/or co-insurance costs.
2. I have read the Consent for Care, Patient Rights and Responsibilities, to include, the State Home Health Hotline phone number, Release of Information, Liability for Payment, Consent to Photograph, Statement of Patient Privacy Rights/Notice About Privacy, Privacy Act Statement – Health Care Records, Notice of Privacy Practices, Your Rights as a Patient to Make Medical Treatment Decisions, Advance Directives, and the Complaint and Grievance Process.
3. I have read Advance Directive for Health Care, Patient Bill of Rights and HIPAA Information.
4. I have read Authorization to Release Information for Payment and Reimbursement Purposes.
5. I have read Authorization for Release of Medical Information.
6. I have read Medicare Secondary Payer Worksheet.
7. I have read the Pinnacle Quality Insight survey notice and its contents.
8. I have received the Quality Improvement Organization (QIO) contact information (Acentra Health: 888-317-0891)
9. I have read and understand the Oxygen Use Waiver.
10. I have read TB Screening upon Admission.
11. I have read and understand the explanation of the Medicare/Medicaid hospice benefit as it applies to emergency/urgent care services.
12. I have read and understand the Consent for Primary Caregiver.
13. I have read and understand the Hospice Insurance Benefit form.
14. I have read and understand the Hospice Services Disclosure form.
15. I have read and understand the Hospice Benefit Authorization.
16. I have read the Emergency Preparedness Plan and its contents.