Spark Home Health - Admissions Packet and Medical History

Admissions Packet
Thank you for working with Spark Home Health! We are grateful to have the chance to support you and your child in your journey through home health services.

We also have a quick video to walk you through what to expect when starting and
receiving services with us!

Please carefully review and complete information on the following pages:
Patient MRN: (H)
Statewise ID (H)
Therapist Name (H)

First NameLast Name
Therapist Email (H)
example@example.com
Has the patient been enrolled in Colorado Medicaid or CHP+ within the last 12 months? (H)
Services (H)
Estimated Cost (H)

Missed Visit Policy
Spark Home Health’s missed visit policy ensures our ability to provide high quality treatment and service to every patient. Our therapists are required to maintain the frequency of visits ordered by your child’s physician to ensure optimal functional outcomes. Your dedicated therapist is committed to the services he or she provides and we ask that you make every effort to keep scheduled appointments.

While we understand that illness, scheduling conflicts and unforeseen circumstances arise we respectfully request you:
- Provide your therapist with at least 24-hours notice prior to changing or canceling a scheduled appointment. Your therapist will make every effort to do the same.
- Cancel appointments only when unavoidable or unforeseen circumstances arise. We reserve the right to discharge your child from Spark Home Health after three no-shows or cancellations within a 60-day certification period. This policy helps ensure our therapy team is able to accommodate every child requesting therapy services.
- Complete make-up visits in-person or via telemedicine when appropriate in order to maintain compliance to physician orders.
We take the safety of your family seriously. If you miss an appointment and have not previously notified your nurse or therapist we will make every effort to contact you. The nurse/therapist will call your emergency contact within 12-hours of your original appointment if he/she has not heard from you. If safety has not been confirmed within 48-hours of your initial missed visit, we will contact your local police department to perform a well check.

Our entire Spark Home Health team appreciates your cooperation with this policy. We look forward to working together so that your child may attain patient centered goals and optimize function throughout their home and community.
Signature of Patient/Authorized Representative

Authorization for Electronic and Telephonic Communication
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Patient Contact / Caregiver

First NameLast Name
Communication Preferences

At Spark Home Health, we want to communicate with you in the way that is most convenient for you. However, we must protect your Protected Health Information (PHI). Please review the information below and indicate your preferences for how we may contact you regarding scheduling, appointment reminders, care coordination, and important updates.
Email Communication
Please read carefully before checking the box below.

We may use email to send you appointment reminders, invoices, or general updates. Standard email is not encrypted. While we take steps to protect your information, we cannot guarantee that emails sent to you will be secure from interception.

By checking "I consent" below, I acknowledge the risks of unencrypted email communication.
Please select:
Email Consent
Phone Calls
Please read carefully before selecting an option below.

Our staff may need to call you to schedule visits, confirm appointments, or discuss care. Calls will be made to the phone number you provided in this form. Before discussing any health information, our staff will confirm they are speaking with you. However, we cannot guarantee that others will not overhear a call if you are in a public or shared space, or that your phone service is secure.

By selecting "I consent" below, I acknowledge these risks. Consent is not a condition of receiving care.
Please select one of the following:
Phone Call Consent:
Voicemail
Please read carefully before selecting an option below.

If we cannot reach you, we may leave a voicemail. We will limit the information left on voicemail to the minimum necessary to accomplish the purpose of the call (e.g., "This is Spark Home Health calling to confirm your appointment tomorrow at 3:00 PM. Please call us back."). However, we cannot guarantee that your voicemail is private. If someone else has access to your phone or voicemail account, they may hear the message.

By selecting "I consent" below, I acknowledge the risks of voicemail communication. Consent is not a condition of receiving care.
Please select one of the following:
Voicemail Consent
Text Message (SMS) Communication
Please read carefully before checking the box below.

The convenience of communicating via text message makes it a widely requested and preferred method of communication between our patients and clinicians. If you consent, your therapist and Spark Home Health staff may text you to coordinate care, including scheduling, appointment reminders/rescheduling, and important updates. Message frequency varies based on your care. Message and data rates may apply. You may opt out at any time by replying STOP to any text message, or get help by replying HELP. Texts will be sent only to the mobile number you provided in this form.

However, using text messages may put your Protected Health Information (PHI) at risk.

The HIPAA Privacy Rule protects most "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or medium, whether electronic, on paper, or oral. Protected health information includes demographic information, and information relating to:
- The individual's past, present, or future physical or mental health or condition,
- The provision of health care to the individual, or
- The past, present, or future payment for the provision of health care to the individual.
The HIPAA Security Rule requires healthcare providers to implement controls to ensure the protection of PHI. The risks in PHI disclosure through text messages include:
- If the sender or receiver loses their device, the messages could be accessed by an unauthorized individual.
- If messages are sent through un-encrypted text messages, the messages could be accessed by an unauthorized individual.
Although entire patient records are not shared via text message, there is a possibility of including information that constitutes PHI throughout the history of text messaging to coordinate care for the patient.

By selecting "I consent" below, I acknowledge that some PHI may be communicated in a non-encrypted medium and therefore may be at risk of being accessed by an unauthorized individual. Consent is not a condition of receiving care.
Please select:
Text Consent
General Consent and Signature

I understand that I may adjust or revoke this consent at any time by submitting a written request to Spark Home Health at admin@sparkhomehealth.com. I understand that standard text messaging and email may not be secure and that Spark Home Health nor any of its employees and/or contractors is/are not liable for unauthorized access resulting from transmission to the contact information I have provided.

Notice of Privacy Practices
Signature of Patient/Authorized Representative

I understand what constitutes Personal Health Information (PHI) and I understand that I am responsible for the content of text messages generated from my device.

Consent for Use of Telemedicine via Live Video Visits
Thank you for your interest in using Telemedicine as service delivery method for you and your child. Colorado law requires that consent be signed prior to the start of services delivered via Telemedicine. Please read the consent information below. You will be provided a copy for your records.

Parent(s)/Guardian Acknowledgment and Statement of Consent I understand that my child and family may receive services via Telemedicine. I understand that Colorado law requires that I consent to the following:
1. I retain the option to refuse the delivery of healthcare services via telemedicine at any time without affecting my child's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which my child would otherwise be entitled.
2. All applicable confidentiality protections shall apply to the services.
3. The services provided via Telemedicine shall meet the same standard of care as in-person visits.
4. The member(s) shall have access to all medical information resulting from the telemedicine services as provided by applicable law for member access to his or her medical records. [C.R.S. 2018, 25.5-5-320(4)]and
5. The above shall not apply in an emergency.
Please choose one of the following
Signature of Patient/Authorized Representative

Infection Control Policies Acknowledgement
At Spark Home Health, we have a responsibility to our patients and their families to strictly adhere to infection control protocols to minimize the spread of infectious diseases. These protocols address several types of disease processes such as influenza, strep, COVID-19, chicken pox, RSV, etc. All of our home health professionals abide by strict infection control precautions including:
- Vaccination against COVID-19 and influenza for all staff members when recommended by state and federal guidelines
- Daily infection control screenings of all direct care staff and patients
- Use of Personal Protection Equipment as recommended by the Centers of Disease Control including by not limited to: KN95 mask, single use surgical masks, eye covering, etc.
- Limited materials brought into the home and bag barriers used when needed
- Strict cleaning protocols for any items brought into the home
- Washing and sanitizing hands prior to each visit and as needed throughout the visit.
Our goal is to ensure each family is aware of the increased risks of exposure during an in-person visit and understands how to protect themselves and others against a variety of infectious diseases. We ask that all of our patients/caregivers sign this acknowledgement of our Infection Control Policies.

By signing below, I confirm the following:
- I understand there is an increased risk of being exposed to or infected by someone with an infectious disease during in-person services.
- I understand that in-person visits increase the risk of exposing or infecting my clinician and others in the community.
- I understand that my clinician will abide by the infection control policies of the agency and that these policies may change based on recommendations from public health organizations.
- I understand that it is my responsibility to follow public health guidelines to protect myself and others in the community.
- I understand that it is my responsibility to answer infection screening questions and to inform my clinician if any member of my household shows any signs or symptoms of illness prior to my in-person visit.
- I understand that telemedicine visits may be used to ensure continuation of care and decrease the risk of spreading infection.
- I understand that I may contact the Spark Home Health, Infection Control Officer, Jenny Vail-Stencel at 720-479-8952, with any questions or concerns with any infectious disease process. I may also review the Centers
  for Disease Control (www.cdc.gov) and the Colorado Department of Public Health (https://cdphe.colorado.gov/) for recommendations for decreasing the spread of infections.
Signature of Patient/Authorized Representative

Authorization to Discuss PHI with Alternate Caregivers

(Daycare, Grandparent, etc.)
Many of our patients allow individuals such as relatives, daycare providers or others to be present during services and speak with our clinical team regarding care and home programming. Under the requirements of HIPAA, we are not allowed to provide information to anyone without the patient or legally authorized representative's consent.

If you wish to have your treatement information discussed with additional individuals or organizations, you must sign this form. Signing this form will only allow verbal information to the individuals or organizations indicated below. The individuals named may also sign the clinical documentation as required to confirm the patient visit has been completed.
Do you have an alternate caregiver (including teachers, aba providers, family members, or family friends) of who may be present during home health appointments? (Even if not actively participating.)
Name of Alternate Caregiver/Entity
Relationship to Child (Family, Friend, School, etc.)
Will services with this alternate caregiver occur at a different location?
Address of Alternate Caregiver/Entity (if services will take place at this location)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have another alternate caregiver to list?
Name of Alternate Caregiver/Entity
Relationship to Child (Family, Friend, School, etc.)
Will services with this alternate caregiver occur at a different location?
Address of Alternate Caregiver/Entity (if services will take place at this location)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Patient/Authorized Representative

I understand I have the right to revoke this authorization at any time and that I have the right to direct and specify the protected health information to be disclosed. I understand that information disclosed to any of the above recipients is no longer protected by federal or state law and may be subject to re-disclosure by the above recipient. You have the right to revoke this consent in writing. I further understand that no information will be transmitted to the above recipients in writing or via email or other electronic means.

Clinical Records
Access to your child’s updated clinical record is important to his or her continued progress toward therapeutic goals. Your child’s updated plan of care, medication list/instructions, therapy program, home exercises, individual goals, schedule, emergency plan, and admission documents are available in printed paper format or via Spark Home Health patient portal via the website shh.statewise.com. You must request to receive this written information electronically.

At times, the agency may share information electronically via encrypted e-mail. In order to access the encrypted e-mail, you will be prompted to create a unique username and password which you can then continually use to access encrypted e-mails sent from Spark Home Health.

Finally, Spark Home Health sends newsletter and other updates regarding information relating to your child’s care, community events or important resources. This information will not be e-mailed in an encrypted format as no protected health information will be transmitted.
Please choose one
Email Address
example@example.com
Signature of Patient/Authorized Representative

Written Notice of Home Care Consumer Rights

Review this important document from Colorado Department of Public Health and Environment and sign to attest
The state of Colorado requires you review and understand the attached notice. Please click the link to review the document. This link includes the document in English and Spanish.

CLICK HERE

Sign below to attest that you have reviewed and understand the Written Notice of Home Care Consumer Rights.
Signature of Patient/Authorized Representative

I attest to verbal and written receipt of the aforementioned notice of rights
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Agency Disclosure Notice

Review this important document from Colorado Department of Public Health and Environment and sign to attest
The state of Colorado requires you review and understand the attached disclosure. Please click the link to review the document. This link includes the document in English and Spanish.

CLICK HERE

Sign below to attest that you have reviewed and understand the Written Notice of Home Care Consumer Rights.
Consumer or Authorized Representative Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Patient or Authorized Representative

The above information and areas of responsibility have been explained and any questions have been answered in regard to responsibilities held by the consumer, the home care worker, and the agency.

Colorado Medicaid Program

(Health First Colorado, Child Health Plan Plus)
Has the patient been enrolled in Colorado Medicaid or CHP+ in the past 12 months?
Home Health Face to Face Encounter Agreement
Colorado Medicaid implemented a mandated Face-to-Face encounter as a requirement of home health services for all admissions after July 1, 2017. Spark Home Health must have documentation stating that each patient has seen his or her Physician/Nurse Practitioner/Clinical Nurse Specialist/Certified Nurse Midwife or Physician Assistant 90 days prior to, or 30 days after the Start of Care. The primary reason the patient is receiving home health services must be documented in the provider’s clinical note. The documentation needs to be sufficient to make the link between the individual’s health condition, the services ordered and actual service provision.

If the patient has had an appointment with his/her physician, nurse practitioner, or physician assistant regarding the need for home health therapy services within the last 90 days, there is no need to make another appointment. A “well child” check up qualifies if you also discussed your concerns for your child’s development and this is documented in the medical record. Our therapists can help you contact your doctor’s office to determine if a recent appointment with your physician meets this requirement.

If you have not had a recent appointment with your physician regarding concerns in development, please schedule the equivalent of a sick child visit to review the patient’s health and development and need for home health therapy services.

I understand the Face-To-Face requirements set forth by Colorado Medicaid. I understand if my child has not had an appointment with his/her physician/nurse practitioner/clinical nurse specialist/certified nurse midwife or physician’s assistant within the past 90 days satisfying the Face-To-Face requirement that I must see my qualified clinician within 30 days of admission to Spark Home Health. If my qualified clinician is not able to produce documentation of a Face-To-Face visit within 30 days of my admission, I understand and agree that my child will be discharged from Spark Home Health, LLC.
Name of Certifying Medical Provider (Physician/Nurse Practitioner/Physician Assistant)

First NameLast Name
Please select one
Date of Completed Face to Face Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Scheduled Face to Face Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Patient/Authorized Representative

NEXT: Patient Medical History

Information you provide in the next section will help your therapist prepare for your child's evaluation. As a home health agency, we are required to do a head to toe review of current and past medical history. If you are able to complete this form at least 2 days prior to your appointment, it will be very helpful. However, you can skip any question you are unsure about or unable to answer. Please make sure to press "Submit" at the end of the form to finalize all signatures you have completed.

If you haven't yet, please save and review this document with important information about home health services you will receive with Spark Home Health!

Please CLICK HERE to save and review important information about home health services you will receive with Spark Home Health!

¡HAGA CLIC AQUÍ para guardar y revisar información importante sobre los servicios de salud a domicilio que recibirá con Spark Home Health!

Rows	Name	Reaction	Treatment
Allergy 1
Allergy 2
Allergy 3
Allergy 4
Allergy 5

Rows	Name	Dose/Frequency	Administration Notes (by mouth, for fever, etc)
Medication 1
Medication 2
Medication 3
Medication 4

Rows	Name	Supplier/Vendor
Item 1
Item 2
Item 3
Item 4
Item 5

Rows	Age	Notes
Sleeping through the night
Rolling Over
Sitting by self
Standing
Crawling
Walking
Using gestures (waving hi, reaching up)
Babbling
First Word
Using 2 words together

Rows	Age	Notes
Sleeping through the night
Rolling Over
Sitting by self
Standing
Crawling
Using gestures (waving hi, reaching up)
Babbling

Admissions Packet

Patient Emergency Preparedness Plan

Patient Information

Parents and Caregivers

Emergency Contacts

Evacuation

Consent to Treat

Statement of Consent

Authorization of Release of Information

Statement to Permit Payment for Home Health Services

Advance Directives

Acknowledgements

Missed Visit Policy

Authorization for Electronic and Telephonic Communication

Consent for Use of Telemedicine via Live Video Visits

Infection Control Policies Acknowledgement

Authorization to Discuss PHI with Alternate Caregivers

Clinical Records

Written Notice of Home Care Consumer Rights

Agency Disclosure Notice

Colorado Medicaid Program

Home Health Face to Face Encounter Agreement

Patient Medical History Form

Medical History

Birth History

Nutrition

Developmental History

Social History

Personal Info

Rows	Amount of assistance
Falling/staying asleep
Using utensils
Drinking from open cup
Dressing
Undressing
Tying shoes
Brushing teeth
Brushing hair
Bathing
Toileting
Washing hands
Managing fasteners (button, zipper, etc.)
Following routines

Rows	Activities/ Child's Mood
Waking up
Morning
Midday
Afternoon
Evening
Going to bed