Homestead Consent Packet

I voluntarily consent to receive care, treatment, and services provided by Homestead Health, including primary care, palliative care, and/or concierge medical services as determined appropriate by my healthcare provider. I understand and agree that:

1. Authorization for Care
   1. I authorize Homestead Health and its care team to provide care, treatment, and services appropriate to my condition.
2. Care Agreement
   1. Services are provided under a flexible care agreement based on my needs, preferences, and goals.
   2. My care may include evaluation, diagnosis, treatment, and care coordination.
   3. No guarantees have been made regarding the results of my care or treatment.
   4. I have the right to ask questions and participate in decisions about my care.
3. Participation in Care
   1. I agree to communicate my needs, concerns, and changes in my condition to the care team.
4. Right to Refuse
   1. I may accept or refuse any part of my care at any time and will be informed of the possible risks or consequences of refusing care.
5. Care Team & Coordination
   1. My care is coordinated by an interdisciplinary team. I consent to Homestead Health coordinating my care with other healthcare providers, facilities, pharmacies, and caregivers as needed for treatment purposes.
   2. I authorize communication via Phone, Voicemail, Text Message, Email, Patient Portal. I understand that electronic communications may carry some risk to privacy.
6. Role of Family/Caregivers
   1. When appropriate, family members or caregivers may assist in my care by:
   2. Following the care plan, assisting with treatments, and supporting ADLs.
7. Services May Include
   1. Nurse Practitioners, Nursing, and social service support
   2. Prescriptions for medications, equipment, and supplies
   3. Coordination with primary and specialty providers

2. Use and Disclosure of Health Information (HIPAA)

1. I authorize Homestead Health to use and disclose my health information for purposes of:
   1. Treatment, Payment, and Healthcare Operations
   2. This includes sharing information with others involved in my care, as permitted by law.
   3. Homestead participates with Health Current, Arizona’s Health Information Exchange (HIE), which allows participating providers, first responders, hospitals, labs, community behavioral health, and physical health providers, post-acute care, etc., to securely share patient information and records. I acknowledge that I received and read the notice of health information practices. I understand that my health information may be securely shared through the HIE unless I complete and return an opt-out form to my healthcare provider

3. Financial Responsibility

1. I understand that I am financially responsible for services provided to me, including any applicable copayments, deductibles, or non-covered services.
2. I agree to:
   1. Provide accurate insurance information
   2. Notify the practice of any changes in coverage
   3. Pay balances in accordance with practice policies
3. I understand that sliding scale, concierge, or non-covered services may require separate agreements or fees.
4. I agree to comply with Homestead Health’s payment policies.

4. Right to Revoke

1. I understand that I may withdraw this consent at any time by notifying Homestead Health. Revocation will not apply to services already provided.

5. Patient rights & responsibilities

1. I have the right to:
   1. Receive respectful, non-discriminatory care
   2. Be informed about my condition and treatment options
   3. Participate in decisions about my care
   4. Refuse treatment to the extent permitted by law
   5. Privacy and confidentiality of my health information
   6. Access my medical records
   7. File a complaint without fear of retaliation
2. I agree to:
   1. Provide accurate and complete health information
   2. Follow the agreed-upon treatment plan
   3. Ask questions when I do not understand
   4. Treat staff and providers with respect
   5. Meet financial obligations
3. I acknowledge that I have been offered or received a copy of the Notice of Privacy Practices and understand my rights regarding my protected health information.

6. Consent for Telehealth Services: Homestead Health may deliver care through telehealth, using secure electronic communication for remote visits. I understand that I can decline or stop telehealth at any time without affecting my care. My privacy will be protected, I’ll be told who is present during sessions, and I can ask anyone to leave. I also understand there may be risks such as interruptions or technical issues.

7. I may withdraw consent at any time

About these programs
After your evaluation, your provider may add you to one or more of the programs below. These programs help us keep an aging-in-place healthcare relationship with you, so your care team can support you at home and between visits as your needs change. By signing this consent, you agree to be enrolled in any of these programs your provider recommends. Here is what each one is:

• Chronic Care Management (CCM): for patients with two or more chronic conditions expected to last at least 12 months or until the end of life, and that place the patient at significant risk of death, acute exacerbation, or functional decline.
• Principal Care Management (PCM): for patients with one serious chronic condition expected to last at least 3 months, where the condition puts the patient at significant risk of hospitalization, decline, or death.
• Advanced Primary Care Management (APCM): a Medicare-covered program for patients whose primary care is provided by our practice. Your care team manages your health between visits, not only during them, and our practice is the main point of contact for all of your health care needs.
• Principal Illness Navigation (PIN): a trained team member helps you understand and move through care for a serious illness, connects you with community and support resources, and works with your other providers.
• Behavioral Health Integration (BHI): adds behavioral health care management, such as screening, a care plan, and regular check-ins, to your primary care. It is optional.
• Transitional Care Management (TCM): extra support for the first 30 days after you leave a hospital or facility, including follow-up contact, medication review, and a follow-up visit.
• Medication Therapy Management (MTM): a review of all of your medicines, including prescriptions, over-the-counter products, and supplements, to make sure they work well together and to help you take them safely.
• Value-Based Care: Homestead Health may take part in arrangements with Medicare or your health plan that tie payment to the quality of your care and your health outcomes. Your health information may be used and shared for this purpose as permitted by law. This does not change your benefits or your right to choose your providers.

What you receive
Depending on the program, your care team may provide: a written, electronic care plan built around your goals (you or your caregiver will receive a copy); medication review and help managing your medications; coordination with specialists, hospitals, home health, your facility, and community services; management of care transitions, including follow-up after an emergency room visit or hospital or facility discharge; and ongoing communication about your health status and care needs by phone, secure messaging, telehealth, or visits where you live. Your care team may include our nurse practitioners, registered nurses, social workers, and other clinical staff working under the direction of your primary care provider.

You acknowledge and understand the following (for any program you are enrolled in):

• Voluntary and easy to stop. Participation is voluntary. You may stop any program at any time by telling any member of your care team or sending a message to our main line. Your request takes effect at the end of the calendar month in which you make it. Stopping a program will not affect your other care with our practice.
• Access. You will have access to care management services. If you are enrolled in APCM, you will also have access to your care team 24 hours a day, 7 days a week for urgent needs, with access to your medical record.
• Information sharing. Your care plan and health information will be maintained and shared electronically with other treating providers and facilities involved in your care, as permitted by law, so your care can be coordinated.
• Cost-sharing. These services are billed to Medicare and/or your insurance, usually once per calendar month, including months without a face-to-face visit. Standard Medicare Part B cost-sharing (coinsurance and deductible) may apply. Your supplemental insurance or Medicaid may cover some or all of this cost.
• Only one practitioner per month. Only one practitioner can provide and bill for the same care management service for you in a calendar month. Please tell us if you receive care management services from another practice.
• Programs are not billed together. While you are enrolled in CCM or APCM, our practice will not separately bill Chronic Care Management, Advanced Primary Care Management, Principal Care Management, or Transitional Care Management for you in the same month.
• Behavioral health is optional. If you also receive behavioral health care management through our practice, it may be billed as an additional service, and cost-sharing may apply.
• Verbal consent. Services may be started based on your verbal consent, but your signature confirms and documents your enrollment.

By signing below, you:

• Authorize Homestead Health to enroll you in, and provide, the care management programs described above that your provider recommends after your evaluation.
• Authorize billing of Medicare and/or your insurance for these services.
• Acknowledge receipt of the information above.
• Questions have been answered to my satisfaction.

I authorize any health care provider, facility, or pharmacy that holds my records to disclose/release the following information, at the request of the individual:

I authorize the release of information to:

Homestead Health

Phone: (602) 755-4508    Fax: (602) 691-0283

Address: 24 W Camelback Rd A514, Phoenix, AZ 85013     Email: office@homesteadhealth.org

I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, receive payment, or eligibility for benefits unless allowed by law. By signing below, I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

 

This authorization expires 90 days after I am discharged from the services of the company named above. I may revoke this authorization in writing at any time by sending a revocation statement to the company above. I understand that the revocation will not apply to information that has already been released. I understand that authorizing the disclosure of this information is voluntary. I understand that any disclosure of information carries with it the potential for unauthorized re-disclosure by the recipient. Photocopies or facsimile of this Authorization shall be considered to be the same as a signed original document.

Patient Agreement: What to Expect From Us and What We Expect From You

One last step. We want you to know what to expect from us and what we ask of you. Please read each item, and if you have questions, let us know.

 1. Reminders and Messages

To remind you about your appointments, you may get emails, texts, and phone calls from Elation, the system we use for your records. We may also text you from our main office line. If you’d rather only get phone calls, just let us know. You can stop texts any time by replying STOP.

2. Access to Your Information

We use a program called Passport, which is built by Elation, to share your information safely with you and your care team. Using Passport is optional, and a family member or representative can use it on your behalf. You acknowledge that your information may be shared this way.

3. Cancellations

Our schedule is built around each person, so when a visit is missed, someone else may have been waiting for that time. Please give us at least 48 hours' notice if you need to cancel or reschedule. A cancellation or missed visit without that notice carries a $50 fee. We understand that hospital stays and emergencies happen, and we will waive the fee in those cases. If we arrive for a home visit and no one answers, we will count it as a missed visit.

4. Forms and Paperwork

We’re glad to help with forms and paperwork. They take 3 to 5 business days to complete, and we cannot rush them, so please ask early. The only exception is paperwork the law requires on a shorter timeline. Completing a form depends on our clinical judgment, so we can’t promise it in every case.

5. Home Visits

We’re honored to be guests in your home. To keep everyone safe and comfortable, please keep pets secured, do not smoke during the visit, and do not display weapons. Please don’t record or photograph our staff or visits without asking first. If a staff member feels unsafe, they may need to leave and reschedule.

6. Respect for Our Team

Everyone has a bad day, and we understand that. Illness, pain, and memory problems can affect how a person feels and acts, and we take that into account. We do ask that patients, family members, and caregivers treat our staff with respect. If someone is rude, hostile, or abusive, we may need to end our care relationship after a first incident. We also can’t take responsibility for care or decisions that happened before you became our patient.

7. Emergencies

We are not an emergency service. If you are having an emergency, please call 911.

8. Your Wishes

Please share copies of any advance directive, healthcare power of attorney, or POLST form with us so we can honor your wishes.