Annual Updates for Clients

Annual Updates with Angels Service LLC:)Thank you for being part of our community.

*A Comprehensive review and medical form may be required to initiate services. Please make sure we have all relevant information to provide care in a safe and comprehensive manner.
Objective of this agreement: To make sure everyone has reminders of rights, that we get feedback, and that we can double check and make sure that we have everything required by rules and regulations.

By continuing services with Angels Service LLC and any contractors or other collaborators of Angels Service LLC you agree and consent to all current rules & regulations and policies & procedures. Current information can be found on http://www.watchingfish.com/the-legal-stuff
Client Information
If this intake is being completed with a translator or verbally please record the reader / translators name here.
CLIENT NAME (PERSON RECEIVING THE SERVICE), first and last *
What is your address?
Email
example@example.com
What phone number is best to call you?
Who should we talk to about services. Such as Mom, Dad, etc. If client's age is above 18, is this person a guardian?
What is the name of your Case Manager? Please list their email address if you have it:
Please let us know about any changes you need.

STATE MANDATED SURVEY

	Yes	No
Do you have advanced directives? *If you don't know what this is the answer is no
Do you want information on advanced directives?
Do you have a physical therapist?
Do you have a occupational therapist?
Do you have speech therapist?
Do you have diabetes?
Do you have seizures?
Do you have a gtube or jtube?
I understand that I need to go to http://www.watchingfish.com if I need to update anything, request a change, etc. or call directly. or review policies and procedures. I know and understand the responsibilities of myself and of Angels Service LLC (details below and on watchingfish.com).
Consent to Treat: I consent to receiving services on my behalf or on the behalf of someone I have the legal right to consent to services for. I understand that if I participate in services not covered by my insurance I am obligated to pay for the service.
Do you understand that your information is protected by HIPAA? The full HIPAA policy is found: https://www.watchingfish.com/the-legal-stuff

Waivers and Agreements
To safeguard your protected health information and ensure confidentiality, weencrypt external electronic communication which contains your confidentialinformation. This practice is designed to provide an extra level of securityfor your personal information, specifically, it requires ther recipient to usea password to access the message. We recognize that individuals or theirpersonal representatives may choose not to receive encrypted emails for avariety of reason. In order to opt out of this requirement, we must receivewritten notification. This release is intend to serve as that notification.

I would like my information to be encrypted Igrant my permission to send electronic communications UNENCRYPTED. Thispermission applies to me, my team, my providers, and anyone else who needsinformation on my behalf, as appropriate.

With the understanding that everyone will make every reasonable effort to prevent accidents, injuries, or other mishaps, I accept and agree to the following: *

	Yes, I agree
The undersigned agrees to indemnify and hold harmless ANGELS SERVICE LLC AND COLLABORATORS for any and all claims, demands, costs, expenses, including reasonable attorney’s fees that ANGELS SERVICE LLC AND COLLABORATORS may suffer as a result of any claim, action. Demand, or judgement against it arising from the participation in programming. Provided, however, that the above and foregoing shall not be construed to indemnify the ANGELS SERVICE LLC AND COLLABORATORS from any act of negligence or fault on the part of ANGELS SERVICE LLC AND COLLABORATORS.
The undersigned, in case of emergency and in the event the primary contact cannot be reached by telephone, does hereby give permission for medical treatment by physician or hospital selected by ANGELS SERVICE LLC AND COLLABORATORS . Such permission shall include any and all medical treatment which is necessary or desirable in the absolute discretion of any such physician or hospital. This medical care shall include, but is not limited to: examinations, treatments, immunizations, injections, anesthesia, surgery, and other procedures, etc.
The undersigned does hereby agree to allow participation of applicant in all activities with ANGELS SERVICE LLC AND COLLABORATORS (except those specified as restricted)
The undersigned gives permission for the applicant to ride in vehicles operated or leased by ANGELS SERVICE LLC AND COLLABORATORS and holds harmless the aforementioned for any accidents related to the ride.
The undersigned recognizes the right of ANGELS SERVICE LLC AND COLLABORATORS, in his/ her absolute discretion, to terminate a client's services at any time due to disciplinary or medical actions which might jeopardize the client’s or client’s / collaborators health or safety while at receiving services. The undersigned further agrees to pick up the client / return home (depending on the details of service) immediately upon being notified of such termination. Fees are nonrefundable in case of above mentioned situations.
The undersigned agrees not to receive services if client has been EXPOSED to a contagious disease within three (3) DAYS of the session scheduled time.
I understand these are only the highlights, further information is below and within our online policy and procedure manual.
Your appointment will include the following during the service time - Consultation, Program Planning and Review, Direct Service, Coaching, Caregiver / Parental Education, Notes and Receipt of Service. Receipt of Service includes a geolocation, timestamp, signature and photo verification. Signature is optional as not everyone is able to sign. It's encouraged to make a little note next to your signature about the length of the session. For example 1 hr = 1 hour. This helps if there is an accidental data entry error on the end or start time. :) Photo is required and may be of client (as some of us like to pose), numbers on house, or other client specific and chosen item. (It is the fail proof verification) Photos are never saved on devices and are only in the encrypted system.
I understand that as independent contractors ANGELS SERVICE LLC does NOT guarantee the quality of work, control schedule or methodology of service provision. This is highly important as any consequence of negligence is the responsibility of the contractor. Any complaints or concerns should be shared as soon as possible with ANGELS SERVICE LLC so that we may work together to resolve conflict and create actions plans for prevention of future concerns / complaints. IF WORKING WITH INDPENDENT CONTRATORS ANY RESPONSIBLILITY DUE TO NEGLIGENCE, ETC. WILL BE TIED TO THE INDEPDENT CONTRACTOR NOT ANGELS SERVICE LLC
You may work with an employee where we as an agency set quality controls and expectations of how services is provided. You may request the status of your provider any time from Angels Service LLC or from your provider directly. All providers are given an ID badge showing their status.
Providers may only provide services that we have received written permission to do from the case managers.
Communication via text messages or other similar platforms such as social media, are not HIPAA compliant. I understand that if I choose use these methods of communication I am waiving my right to HIPAA in those instances.
We will never send your a bill for services approved by your waiver. The only time you pay for services is if you have made a prior arrangement for private pay services or if you no longer qualify for a waiver and didn't tell us.

Client Details
Have you experience a critical event such as a serious injury, arrest, or a safety control procedure such as having to be restrained in order to protect yourself or others in the last year? (This is another state tracking question). *
Details about your critical event and/or safety control procedure from this year. Please include dates.
***What's happened this year that we should know about, new likes, dislikes, growths or new needs. This goes into the characteristics section and is just a chance to share information that you know is important about yourself or the person you care for. *
Example: I am a fun hearted little girl who loves to laugh, cuddle, play puzzles, stackers, read picture books, watch movies, and ride my special three wheeled bike. I also really hate spaghetti noodles.
What medicines are you taking? This is important in case something happens when we are out and a doctor needs to know or if you are receiving massage sometimes certain medicines can be contraindicated. If it is a long list or you don't want to type it out you are welcome to attach a file. *
If you have any medication lists, doctor notes, seizure plans, etc. that you want us to have.

Browse Files

Cancel of
SEIZURE, DIABETES, ALLERGIES, BEHAVIORS THAT CAN HURT YOU OR OTHERS.... We need an action plan for each one. The The action plan is our instructions on what we need to look out for, what we need to avoid, and what do we need to do if a seizure, allergy, behavior, or diabetic episode happens when we are with you / client? You are welcome to write out the details or upload doctors orders, behavior plans, etc. Write None if this does not apply. *
Reminders
Consent, Expectations and Discontinuation

Active participation in services makes for better services. These are all voluntary and you may influence your services or quit at any time.
Updates

If you need us to know anything please reach out.
90 Day Reviews

We check in every three months, sometimes in person and sometimes by talking to the providers.
HCA Agency Disclosure
HCA Client Rights
Everyday Language: Rights
Everyday Language: Disputes
Everyday Language: Complaints
Everyday Language: Emergencies
Required Release of Information
I understand that to receive services, it is an inter-agency collaboration and that information about my child and family will be shared between needed agencies for
support, planning, and developmental. This includes my local Community Center Board, State agencies, Contractors, and Inter-Disciplinarian team members.

I hereby authorize the mutual exchange of information regarding the named person and the agencies / individuals listed on this form. INCLUDING, NOTES, CLIENT DETAILS, PHOTOS, VIDEOS, OTHER WORK SAMPLES, AND PROFESSIONAL OPINIONS.

There is a focus on trans-disciplinarian teamwork, this means that professional from different backgrounds will discuss different details and strategies to improve services.

I have been fully informed of the intended use of this information sharing. I also understand that the agency / person receiving this information is obliged to maintain it in a confidential manner and it is to be used only for the purpose I have authorized. I understand that this information will be kept in a database that is password protected,and for the exclusive goal of optimizing communication, resources, and supports for (myself, child, and / or family).
Signature showing that you have received required documents. See above.

If you would like a copy of these mailed or emailed please call 720-256-8875 or email care@watchingfish.com
Signature of the person legally able to consent and verify this form the included acknowledgements. *

First Name Last Name

Required forms.

	Yes, I have seen the form and been provided with the option to receive a paper copy if I want one for my records.
HCA consumer rights
HCA agency discloures
Everyday language about rights
Everyday language about disputes
Everyday language about conflicts
Everyday language about emergency planning

Signature

Clear
Relationship between person completing or helping facilitate the completion of the form and client *
Any notes you have

Optional Survey

	No	Somewhat	Yes
I like being able to do this online
I would rather get this in the mail and mail back my signatures
I am happy with Angels Service
I am happy with all my providers
I am happy with some of my providers
My services help me
I need help and would like to schedule a meeting
I would rather have an online account where I log in and update everything each year than a one time form like this
Should we make the annual update just about the required forms and waivers and delete the rest to make it shorter
Should we rely on families and clients to update us through out the year on things like seizures, medicines, and therapy so that we don't have to do it on the annual update

Should be Empty:

Annual Updates with Angels Service LLC:)Thank you for being part of our community.

Client Information

Waivers and Agreements

Client Details

Reminders

Consent, Expectations and Discontinuation

Updates

90 Day Reviews

HCA Agency Disclosure

HCA Client Rights

Everyday Language: Rights

Everyday Language: Disputes

Everyday Language: Complaints

Everyday Language: Emergencies

Required Release of Information

Signature showing that you have received required documents. See above.