HUMAN TOUCH HOME HEALTH CARE AGENCY, INC.
3629 N Sepulveda Blvd., Suite 101, Manhattan Beach, CA 90266
Tel: (424) 247-8165
1122 W Ave L12 Suite 103, Lancaster, CA 93534 Tel: (661) 726-4200

I hereby give my consent and authorized HUMAN TOUCH HOME HEALTH CARE AGENCY, INC., its agents, and associate to provide services to me in my home or place of residence per program policy and/or as prescribed by my physician. A representative of this agency has explained to me the services to be provided and my plan of care. I understand that the plan of care may change and if so, these changes will be discussed with me. I further understand that I and/or my family/caregiver will participate in my plan of care and will receive instructions with my care and that my care will therefore become my responsibility to notify my physician or other care providers of any adverse effects or significant events relating to my health.

I certify that all information given by me to the agency is correct to the best of my knowledge. I understand that payment of authorized benefits be made in my behalf and services provided to me will be billed to the following:

I understand and agree to pay deductibles, co-payments and any amounts due after payments of benefits on my behalf by any and all third party payers. Payments of benefits on my behalf by Medicare/Medi-Cal shall be considered as full.

I hereby consent and authorize the agency to disclose and release information contained in my clinical record to the health providers involved in my care, third party payers, utilization review and professional standards review organizations, regulatory review entities and any other companies that may/will help to meet my health needs. Consent is given for the release of information to HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. by any insurer and all other agencies or individuals from whom medical or social services have been received. Permission is granted for medical facilities to disclose all or part of my medical record to HUMAN TOUCH HOME HEALTH CARE AGENCY, INC.

I have received a copy and written explanation of the Patient Rights and Responsibilities.

In the event that my care is considered non covered by Medicare, I request that HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. represent me in reconsideration and appeal hearings on my behalf to the fiscal intermediary.

HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. and I agree that services are rendered without regard to race, sex, color, religion, handicap or national origin. This agreement is only applicable to this admission to HUMAN TOUCH HOME HEALTH CARE AGENCY, INC.

I hereby agree to inform HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. of any changes in my Medical coverage by signing over my Medicare benefits to another medical insurance entity such as HMO, PPO, IP. I understand that I may be liable for services rendered to me if I failed to inform the agency, of such action.

I hereby authorized HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. staff to use computerized documentation of the care rendered during skilled nursing/therapy visits. I believe that these computerized documentation are properly protected by the staff, and the home health agency based on their Policy and Procedure on the privacy of computer generated documentation, and that no one else has access to the computer files where documentation are generated from.

I hereby authorizes the agency staff and the attending physician to photograph or permit other persons to photograph while under the care of the above named Agency. The undersigned agrees that the above named Agency and the attending physician may use and permit other persons to use the negatives or prints prepared from such photographs for such purposes and in such manner, as either may deem appropriate. The undersigned agrees the photographs may be used for purposes including, but not limited to educational, treatment, research, scientific, public relations, and charitable purposes and that such dissemination may be accomplished in any manner.

Page 1 of 5 (Client's Consent/Admission Service Agreement)

As a client, you have to:

• Be fully informed of your rights and to receive this notice before the initiation of care.
• Be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment, and care for personal needs.
• Have your property treated with respect
• Exercise your rights (or your family or guardian may exercise your rights if you have been judge incompetent) and voice grievance regarding care or lack of respect for property without being subject to discrimination or reprisal.

You may voice these complaints by calling or writing to:

Director of Patient Care Services
3629 N Sepulveda Blvd. Suite 101
Manhattan Beach, CA 90266
(424) 247-8165

Branch: 
Director of Patient Care Services
1122 W Ave L12 Suite 103,
Lancaster, CA 93534
(661) 726-4200

The Department of Health Services
Licensing and Certification Division
3400 Aerojet Ave Suite 323
El Monte, CA 91731
24 Hour HOTLINE Number, 7 days a week
1 (800) 228-1019 The purpose of this Hotline number is to receive complaints or questions about local Home Health agencies. The client also has the right to use this hotline to lodge complaints, concerning the implementation of the Advance Directive Requirements.

Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Tel No: (800) 994-6610

• Be informed in advance about the care to be provided, and of any changes in the care to be furnished.
• Be informed in advance of the discipline that will furnish care, and the frequency of visits proposed to be furnished.
• To participate in the planning of your care or treatment and in planning changes in the care or treatment.
• To be advised orally and in writing, before care is being initiated, of the extent to which payment for home health services may be expected from Medicare, Medi-Cal or other sources, and the extent to which you may be required to pay for the services.
• To be informed orally, and in writing of any changes in the payment information as soon as possible, but no longer than thirty (30) days, from the date the agency becomes aware of the change.

Page 2 of 5

(Client's Consent/Admission Service Agreement)

• Receive written information on your right, under California law to make health care decisions and to formulate advance directives and to expect the Agency to respect your decisions within the confined of States Federal Laws.
• Receive appropriate information from a physician within the limits determined by the physician, law or regulation, regarding your diagnosis, prognosis and treatment.
• Be instructed regarding your illness so you can help yourself and your family, so they can help you.
• Receive the care necessary to promote a maximum state of health and to expect that the care provided by HUMAN TOUCH HOME HEALTH CARE AGENCY, INC., personnel who are qualified through education and experience to perform the services for which they are responsible.
• Refuse treatment and be informed of the medical consequences of such refusal.
• To the confidentiality of your personal and medical reports and to approve or refuse their release to any individual outside of the Agency except in the case of transfer to another health facility or as required by law or third party treatment contract. Care covered by Medicare is subject to review by Peer Review Organization for Cooperative Projects for Quality improvement for patient to help clients make informed health care choices.

• Remain under a doctor's care while receiving skilled Agency services.
• Provide the agency with a complete and accurate health history.
• Provide the Agency with all requested insurance and financial records.
• Sign the required consents and releases for insurance billing.
• Participate in you plan of care.
• Accept the consequences for any refusal of treatment or choice of noncompliance including changes in reimbursement eligibility.
• Provide a safe home environment in which your care can be given.
• Protect your valuables by storing them carefully in an appropriate manner.
• Cooperate with your doctor, Agency personnel and other family members as caregivers.
• Treat Agency personnel with respect and consideration.
• Advise the Agency of any problems or dissatisfaction with care.
• Notify the Agency when unable to keep appointments.
• Provide a copy of an advance directive, if one exists.

Page 3 of 5 (Client's Consent/Admission Service Agreement)

Outcome and Assessment Information Set (OASIS)

This home health agency is a certified and participating provider of home health services in the Medicare program. As part of the conditions of Participation, this Agency is required to collect health care information and data on all patients, regardless of whether they are enrolled in Medicare. This information is collected through the Outcome and Assessment Information Set (OASIS) transmitted to the Health Care Financing Administration, a division of the US Department of health and Human Services, to be used to evaluate and report on the quality of home health services provided by home health agencies. This home health agency will release OASIS information only as authorized by you. Patient identifiable OASIS information will not be released to the public by this agency or any agent acting on our behalf except as authorized by you. There are no penalties for refusing to supply information or authorize release of information. However, failure to furnish the information or authorize its release would prevent this home health agency from provide services to you.

I authorize HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. to release to the Health Care Financing Administration or its agent any information contained or included in the Outcome and Assessment Information Set (OASIS). I permit a copy of the authorization to be used in place of the original.

I have received a copy of the "Statement of patient Privacy Rights" and "Privacy Act Statement Health Care Records" and both had been explained to me by the Home Health Staff.

I, the undersigned consent to the use of disclosure of protected health information about me for treatment, payment and health operations.

HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. Privacy Practices with respect to the uses and disclosures of protected health information were discussed with me. For a more complete description of such uses and disclosures, I was provided a copy of HUMAN TOUCH HOME HEALTH CARE AGENCY, INC.'s NOTICE OF PRIVACY PRACTICES.

I have also been informed that:

• I have the right to review the "NOTICE OF PRIVACY PRACTICES" under HIPAA regulation.
• I have the right to request restrictions on uses or disclosures of my health information for treatment, payment, and health care operation purposes. HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. is not required to agree to requested restrictions but is bound by any restriction to which it agrees.
• I have the right to revoke this consent in writing, except to the extent that HUMAN TOUCH HOME HEALTH CARE AGENCY, INC. has already taken action in reliance on the consent.

I have received a copy of the "NOTICE OF PRIVACY PRACTICES" and had been explained to me by the Home Health Staff.

Page 4 of 5 (Client's Consent/Admission Service Agreement)

I hereby give my consent, and acknowledge that I have understood all the information on page 1-5 of this Client's Consent/Admission Service Agreement which were explained to me by the staff of HUMAN TOUCH HOME HEALTH CARE AGENCY, INC.

Page 5 of 5 (Client's Consent/Admission Service Agreement)