INITIAL SCREENING & PHI AUTHORIZATION

INITIAL SCREENING & PHI AUTHORIZATION

First-stage home-care inquiry
1. Cathy Home Care Employee Collecting Form

This Section 1 is to be completed by the employee.
Employee Code
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2. REQUIRED PATIENT INFORMATION
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medicaid ID
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security number (Optional)
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person (If any)

First NameLast Name
Relationship with patient
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
3. SERVICES NEEDED OR BEING CONSIDERED
Personal Care Supports:
Medical and health-related needs:

Other
Transportation and community services:
Other needs
Please briefly describe any other services or support the patient may need.
4. CRITICAL FIRST-STAGE QUESTIONS
Diagnosis (es):
Health Condition:

Other
Primary Doctor Full Name
Primary Doctor Contact
Primary Doctor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Doctor Fax
Additional Comments
5. AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who may disclose information. I authorize my healthcare and benefit-related providers and organizations, including physicians, hospitals, clinics, pharmacies, medical equipment suppliers, home health providers, caregivers, Medicare, Medicaid, Medicaid managed-care plans, and health or social-service programs, to disclose the information described below to Cathy Home Care.

Who may receive and use information. I authorize disclosure to Cathy Home Care, its workforce members, and its business associates that perform services for Cathy Home Care under applicable privacy and security obligations, including secure information-technology and data-processing services.

Information covered. I authorize disclosure of demographic and contact information; Medicare and Medicaid enrollment, eligibility, benefit, claim, billing, authorization, and service-coordination information; medical records; diagnoses; medication lists; treatment and service plans; orders; assessments; discharge information; and information about functional limitations and home-care needs.

This authorization does not include psychotherapy notes or records subject to special substance-use-disorder confidentiality rules unless I complete a separate authorization that specifically permits their disclosure.

Purpose. Cathy Home Care may use or disclose this information to evaluate my service needs; verify Medicare or Medicaid eligibility, benefits, or authorization; determine whether Cathy Home Care can provide the requested services; arrange, coordinate, or manage home-care services and related supplies; communicate with providers and benefit programs to assist me with benefits when neccessary; support continuity of care; and securely process this form.

Permission to discuss care. I permit Cathy Home Care to discuss my care, treatment, eligibility, benefits, authorization, and service arrangements with the persons and organizations described above when reasonably necessary for these purposes.
OPTIONAL PERSON(S) CATHY HOME CARE MAY SPEAK WITH

First NameLast Name
Relationship with patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EXPIRATION

This authorization expires 12 months after the date I sign it, unless I revoke it earlier in writing.

I UNDERSTAND THAT
- I may revoke this authorization at any time by sending written notice to Cathy Home Care at 7601 W Sam Houston Pkwy S, Suite 818, Houston, TX 77072. Revocation will not affect actions already taken in reliance on this authorization.
- Information disclosed under this authorization may be redisclosed by a recipient as permitted or required by law and may no longer be protected by HIPAA.
- Cathy Home Care will not condition treatment, payment, enrollment, or eligibility for benefits on signing this authorization, except when permitted by law.
- I may refuse to sign. Refusal may limit Cathy Home Care's ability to obtain information needed to evaluate or coordinate services, but it does not by itself cancel my Medicare or Medicaid benefits.
- I am entitled to receive a copy of this signed authorization.
PATIENT / AUTHORIZED REPRESENTATIVE ACKNOWLEDGMENT

I certify that the information in this form accurately reflects information given by me or on my behalf on the date signed. I understand that Cathy Home Care will use this information as the basis for scheduling a deeper eligibility review and, if appropriate, an assessment. I agree to be screened and assessed for Medicare and/or Medicaid home-care services for which Cathy Home Care may provide or may coordinate support.

By signing below, I authorize the disclosures and uses of PHI described in this form.
Patient or Authorized Representative Signature
Sign Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship With Patient
Authority To Sign, If Not Patient
Describe authority. Cathy Home Care may request documentation of this authority.
Should be Empty:

INITIAL SCREENING & PHI AUTHORIZATION

1. Cathy Home Care Employee Collecting Form

2. REQUIRED PATIENT INFORMATION

3. SERVICES NEEDED OR BEING CONSIDERED

4. CRITICAL FIRST-STAGE QUESTIONS

5. AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

EXPIRATION

I UNDERSTAND THAT

PATIENT / AUTHORIZED REPRESENTATIVE ACKNOWLEDGMENT