Consent to Receive Services

I hereby give my permission for authorized personnel of your agency, Compassionate Care In Christ Home Care to made reasonable effort according to applicable law to render appropriate Non Medical Home Care Service such as Companion and/or Personal Care services to the client named above. I understand an appropriate level of home care personnel will provide such care. I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying Compassionate Care In Christ Home Care Agency. In addition, Compassionate Care In Christ Home Care Agency may terminate service by notifying me of termination and the reason.

“Companion services” means non-medical, basic supervision and socialization services that do not include assistance with activities of daily living and that are provided in an individual’s home. “Companion services” may include the performant of household chores “Personal care services” include bathing, toileting, transferring, dressing, grooming, and assistance with ambulation, exercise, or other aspects of personal hygiene. “Non Medical Service does not provide skills care or nursing care.” “Live In Clients, must provide the caregiver with private quarters in a homelike environment. “Live In Clients, sleep time requirements call for consideration of the particular circumstances of the case. “Live In Clients, is responsible for providing meals for the caregiver, as the caregiver is responsible for preparing, cooking clients meals.

At any time while receiving services from Compassionate Care In Christ Home Care Agency and in the event of any medical emergency, I authorized Compassionate Care In Christ Home Care Agency or its employees/ Contractors to provide or obtain such medical treatment as they deem advisable under the circumstances, and I agree to assume sole responsible of such treatment.

Medical Records

I hereby consent and request that copies, if necessary, of my prior medical records be delivered to Compassionate Care In Christ Home Care Agency to establish or continue my home care plan. I hereby authorize Compassionate Care In Christ Home Care Agency to release copies of my medical records or reports or such portions or summaries thereof as may be relevant, to other health care providers or regulatory or accrediting bodies for the purpose of continuing and coordinating my home care plan and for quality assurance, survey and accreditation purposes.

Release of Vehicle

I agree to notify Compassionate Care In Christ Home Care Agency in advance, and I understand that I must receive written authorization from the Compassionate Care In Christ Home Care Agency before any Compassionate Care In Christ Home Care Agency employee/contractor may operate my automobile or transport me in a Compassionate Care In Christ Home Care Agency employee's/contractor's automobile.I understand and agree that it is my responsibility to maintain automobile liability insurance at the minimum level established by the state covering my automobile and authorized drivers, including Compassionate Care In

Christ Home Care Agency employees/ contractors, should I permit a Compassionate Care In Christ Home Care Agency employee/contractor to operate my automobile. I understand and agree that Compassionate Care In Christ Home Care Agency does not provide insurance coverage under any circumstances for any damages to my automobile, bodily injury, or damage to property resulting from the use of my automobile by Compassionate Care In Christ Home Care Agency. I hereby release Compassionate Care In Christ Home Care Agency and its employees/contractors assigned to me, and hold Compassionate Care In Christ Home Care Agency and such employee/contractors harmless and indemnify them from any claim, liability, or cause of action for any injury to my person (including death ) bodily injury to a third party; or property damage resulting from the use of an automobile (whether or not owned by me) if operated by a Compassionate Care In Christ Home Care Agency employee/contractor, whether or not prior authorization from Compassionate Care In Christ Home Care Agency has been obtained.

Statemen ts of Patient Bill Of Rights

I certify that I have read, received a copy, and understand the Patient Bill of Rights which has been explained to me orally by a representative of Compassionate Care In Christ Home Care Agency.

Deposits

Note: This form must be signed by the Home Patient/client unless the patient/client is under legal contractual age (minor), incompetent, or physically Incapable of signing

I have read and fully understand the content of the four-page Consent Form and hereby agree to and authorize the foregoing provisions. As used in this document, the terms "I," "me" and "my" refer to and include, in addition to the undersigned, chat patient/ client named above and others for whom the undersigned is responsible or for whom the undersigned has assumed responsibility in engaging CCCHHA to provide service to the patient/client.

Note: This form must be signed by the Compassionate Care In Christ Home Healthcare Agency Patient/Client unless the patient is a minor, incompetent, or physically incapable of signing

To attempt to keep all our clients informed and educated in a changing, dangerous world, Compassionate Care in Christ Home Healthcare Agency wants to give you the best advice and preparedness tips possible. When your service began, we assigned you a priority code based on your own unique situation at home.

DISASTER EMERGENCY PRIORITY CLASS

➢ CLASS I - Life threatening (or potential) - requires ongoing medical treatment/care. Any equipment dependent upon electricity should be listed with the power company. Oxygen dependent clients should be supplied with a back-up tank from the supplier. Does not have a caregiver capable of providing care. Requires assistance with transportation to hospital or specialized shelter.

➢ CLASS II - Not life threatening but client might suffer severe adverse effects from interruption of services, ie. daily insulin, IV meds, sterile wound care with large amounts of drainage, symptoms controlled with difficulty, death appears imminent. Capable caregiver present. Will require transportation assistance to hospital or specialized shelter.

➢ CLASS III - Visits could be postponed 24-48 hours without adverse effects, ie. sterile wound care with a minimal amount to no drainage, symptoms need intervention, but are fairly well controlled. Able to care for self or willing/able caregiver. Transportation available from family, friends, or others.

➢ CLASS IV - Visits could be postponed 72-96 hours without adverse effects, ie. symptoms well-controlled. Able to care for self or willing and able caregiver. Transportation available from family, friends, or others.

During an emergency situation, Compassionate Care in Christ Home Healthcare Agency clients can expect that we will do everything within our means to continue servicing your emergent needs. Some of the situations that may cause us to close an office and put the emergency plan in effect are:

• Severe winter storms
• Severe weather conditions (hurricane, tornado etc.)
• National Emergency status called for by the Governor
• Terrorist attack
• Pandemic threat such as Covid-19

In the event that we have some notification of the emergency situation, you can expect a phone call from our office explaining when we anticipate your next visit to be done and by whom. If you are a priority 2, 3 or 4 client, we are likely to postpone your scheduled visit to another day in the same week. If you are a priority 1 client, we will make every effort to provide a visit.

We advocate the State’s suggestion that all persons create a 2-day supply of clean drinking water, canned/ nonperishable food, flashlight with extra batteries, extra blanket, 2-day supply of medication, and portable radio. Please take some time now to be sure these are in place BEFORE an emergency event should occur. When an emergency condition occurs, our office begins specialized procedures. The Administrator will begin notifying his/her staff and the phone tree continues until all employees are contacted so that everyone knows what to do and when to do it. Please refrain from calling the office unless you have a true emergency situation as our offices are likely to be very busy during the time of an emergency. We will be calling you to keep you informed.

CONSENT TO TREAT: I hereby authorize Compassionate Care in Christ Home Healthcare Agency and its agents’ full consent for the provision of care and treatment under the plan of care and to abide by Compassionate Care in Christ Home Healthcare Agency’s specific policies and procedures relating to home care which have been reviewed with me and which include provisions for termination of home care services at my request, my representative’s request and/or Compassionate Care in Christ Home Healthcare Agency’s request. I acknowledge that no guarantees have been made with respect to the outcome of this service.

PHOTO CONSENT: I hereby give Compassionate Care in Christ Home Healthcare Agency and its staff, consent to photograph me and any parts of my body, in relation to my care/services while under the care of Compassionate Care in Christ Home Healthcare Agency.

ELECTRONIC RECORDS/SIGNATURES CONSENT: if our agency utilizes an electronic record system, I give my consent to the use of electronic records & e-signature use.

I acknowledge that Compassionate Care in Christ Home Healthcare Agency does not routinely perform drug testing on employees but may do so at their discretion.

I consent to the proposed Care Plan and authorize care be provided by Compassionate Care in Christ Home Healthcare Agency under supervision of Compassionate Care in Christ Home Healthcare Agency staff. I understand that I have the right to refuse treatment or terminate care at any time by providing Compassionate Care in Christ Home Healthcare Agency.

CONSENT TO TREAT: I hereby authorize Compassionate Care in Christ Home Healthcare Agency and its agents’ full consent for the provision of care and treatment under the plan of care and to abide by Compassionate Care in Christ Home Healthcare Agency’s specific policies and procedures relating to home care which have been reviewed with me and which include provisions for termination of home care services at my request, my representative’s request and/or Compassionate Care in Christ Home Healthcare Agency’s request. I acknowledge that no guarantees have been made with respect to the outcome of this service.

PHOTO CONSENT: I hereby give Compassionate Care in Christ Home Healthcare Agency and its staff, consent to photograph me and any parts of my body, in relation to my care/services while under the care of Compassionate Care in Christ Home Healthcare Agency.

ELECTRONIC RECORDS/SIGNATURES CONSENT: if our agency utilizes an electronic record system, I give my consent to the use of electronic records & e-signature use.

I acknowledge that Compassionate Care in Christ Home Healthcare Agency does not routinely perform drug testing on employees but may do so at their discretion.

I consent to the proposed Care Plan and authorize care be provided by Compassionate Care in Christ Home Healthcare Agency under supervision of Compassionate Care in Christ Home Healthcare Agency staff. I understand that I have the right to refuse treatment or terminate care at any time by providing Compassionate Care in Christ Home Healthcare Agency.

I have supervised the CHHA and found him/her to be competent/not competent (circle one) to carry out the duties required based on the client’s care plan.

I received a copy and understand the Patient's Bill of Rights and Grievance/Complaint policy and understand that the client may be discharged/transferred if goals are met or other services become necessary to maintain proper care for the client. I may not hire any Compassionate Care in Christ Home Healthcare Agency employee privately for at least ninety days after discharge from the agency's services.

I give consent for Compassionate Care in Christ Home Healthcare Agency to provide the above home health services, along with consent for the release of information necessary to provide those services to the client noted below. I also give consent for the release of information necessary for any governing body to complete an audit of Compassionate Care in Christ Home Healthcare Agency services.

I have read and understand the services and charges for Compassionate Care in Christ Home Healthcare Agency services. I have received a copy of the Service/Rate sheet and understand that I will be billed weekly. I agree to pay Compassionate Care in Christ Home Healthcare Agency on a timely basis and understand that invoices are due upon receipt. I also understand that if payment is delinquent by 30 days, Compassionate Care in Christ Home Healthcare Agency may terminate service. Compassionate Care in Christ Home Healthcare Agency reserves the right to require a security deposit from new or delinquent clients, prior to the start or continuation of care.

I understand that if at any time I receive a warning letter for "termination of service", due to past due invoices, it will be my responsibility to pay all open invoices on the account including a security deposit for service to continue. The security deposit will be in the amount equal to two weeks' invoices and must be received within 5 days of security notification.

The rates, terms and conditions are subject to change by Compassionate Care in Christ Home Healthcare Agency on prior written notice. The Client or Responsible Party may, by written notice to Compassionate Care in Christ Home Healthcare Agency, terminate this Service Agreement if new rates, terms or conditions are not acceptable. If Compassionate Care in Christ Home Healthcare Agency does not receive written notice of termination prior to the effective date of the new rates, terms or conditions, they shall be considered effective and binding. This agreement may not be modified verbally.

I have read and understand the Service/Payment Agreement. I give consent to Compassionate Care in Christ Home Healthcare Agency to provide services.

The undersigned understands that if the Client requests and is rendered services additional to those authorized by Medicaid and/or its Contract Source, then the Client/Responsible Party will be billed and responsible for the costs of those additional services. As undersigned, I have received a copy of Compassionate Care in Christ Home Healthcare Agency’s Service/Rate Sheet.

I received a copy and understand the Patient's Bill of Rights and Grievance/Complaint Policy and understand that the Client may be Discharged/Transferred if goals are met or other services become necessary to maintain proper care for the Client.

I give consent for Compassionate Care in Christ Home Healthcare Agency, to provide the above home health services, along with consent for the release of information necessary to provide those services to the Client noted below. I also give consent for the release of information necessary for any governing body to complete an audit of Compassionate Care in Christ Home Healthcare Agency, services.

The undersigned ("Responsible Party") is the Client, Responsible Party, or a Designated Individual of the client noted below, and is authorized to enter into and sign this Agreement. The billing procedure of Compassionate Care in Christ Home Healthcare Agency requires each employee(s) assigned and providing service(s) to this case to complete a time slip to be presented for signature at the end of each week or when service by the employee ceases. The time slip indicates the number of hours of service rendered each day during the period covered by the time slip. The time slip will be signed by the Client, the Responsible Party, or a Designated Individual, and will be used by Compassionate Care in Christ Home Healthcare Agency, to compensate our employee and generate a weekly invoice for service to Medicaid and/or its contracted source.

The terms and conditions are subject to change by Compassionate Care in Christ Home Healthcare Agency, or Funding Source on prior written notice. The Client or Responsible Party may, by written or verbal notice to Compassionate Care in Christ Home Healthcare Agency, terminate this Service Agreement if new terms or conditions are not acceptable. If Compassionate Care in Christ Home Healthcare Agency, does not receive written notice of termination before the effective date of the new terms or conditions, they shall be considered effective and binding.

I have read and understand the Service Agreement. I give consent to Compassionate Care in Christ Home Healthcare Agency, to provide service.

 The undersigned understands that if the client, requests and is rendered services additional to those authorized by the funding source, then the Client/Responsible Party will be billed and responsible for the costs of those additional services. I have received a copy of Compassionate Care in Christ Home Healthcare Agency’s Service/Rate Sheet.

I received a copy and understand the Patient's Bill of Rights and Grievance/Complaint Policy and understand that the Client may be Discharged/Transferred if goals are met or other services become necessary to maintain proper care for the Client.

I give consent for Compassionate Care in Christ Home Healthcare Agency, to provide the above home health services, along with consent for the release of information necessary to provide those services to the client noted below. I also give consent for the release of information necessary for any governing body to complete an audit of Compassionate Care in Christ Home Healthcare Agency services.

I give consent for Compassionate Care in Christ Home Healthcare Agency, to provide the above home health services, along with consent for the release of information necessary to provide those services to the client noted below. I also give consent for the release of information necessary for any governing body to complete an audit of Compassionate Care in Christ Home Healthcare Agency services.

The undersigned ("Responsible Party") is the Client, Responsible Party, or a Designated Individual of the client noted below and is authorized to enter into and sign this Agreement. The billing procedure of Compassionate Care in Christ Home Healthcare Agency requires each employee(s) assigned and providing service(s) to this case to complete a time slip to be presented for signature at the end of each week or when service by the employee ceases. The time slip indicates the number of hours of service rendered each day during the period covered by the time slip. The time slip will be signed by the Client, the Responsible Party, or a Designated Individual, and will be used by Compassionate Care in Christ Home Healthcare Agency, to compensate our employee and generate a weekly invoice for service to the proper funding sourc.

The terms and conditions are subject to change by Compassionate Care in Christ Home Healthcare Agency, or funding source on prior written notice. The Client or Responsible Party may by written notice to Compassionate Care in Christ Home Healthcare Agency, terminate this Service Agreement if new terms or conditions are not acceptable. If Compassionate Care in Christ Home Healthcare Agency, does not receive written notice of termination before the effective date of the new terms or conditions, they shall be considered effective and binding. This agreement may not be modified verbally.

I have read and understand the Service Agreement. I give consent to Compassionate Care in Christ Home Healthcare Agency, to provide service.

 

A. Patient Rights As a client of the Agency, you have the right to the following:

• Be given a written notice about your rights and responsibilities for receiving home health services in advance of care provided to you or during the initial assessment visit before the initiation of treatment.

• Permit your family or guardian to exercise your rights when your Physician has determined that you are incapable.

• Be assured of your civil and religious liberties, be given appropriate and professional quality home health care services without discrimination against your race, creed, color, religion, sex, national origin, sexual preference, physical, mental, emotional impairment or age.

• Be given an initial assessment; participate in the planning, implementation and updating of your care plan to meet your unique healthcare needs.

• Voice grievances regarding treatment or care that is or that fails to be provided, without being subjected to discrimination or reprisal for doing so.

• Patients are encouraged to voice concerns by calling a Client Service Representative at Compassionate Care in Christ Home Healthcare Agency (856) 433-7222. All complaints are kept strictly confidential. Complaints are reviewed and responded to within 5 days by the agency.

• Be advised in writing of the availability and telephone number for the purpose of receiving complaints or questions regarding local healthcare agencies. Call: The Division of Consumer Affairs, 973-504-6200 or 800-242-5846, Division of Disability Services for PCS Services 609-631-4365 or 888- 285-3036 and The Commission on Accreditation for Home care at 201-880-9135

• Receive timely response from the agency regarding your request for home health care services, and to receive the highest quality of care to maximize the quality of life; be treated with courtesy and respect by all who provide home health care services to you.

• Be free from physical and mental abuse; be given proper identification by name and title of everyone who provides home health care services to you. • Be given the necessary information in advance about your care, so that you will be able to give informed consent for your treatment.

• Be given complete and current information concerning your diagnosis, treatment, alternatives, risks, and prognosis as required by your physician’s legal duty to disclose, in terms and language you can reasonably understand.

• Be given written information concerning your rights to accept or refuse medical care and to formulate advanced directives.

• Be assured that your clinical records are maintained in a confidential manner. Release of information is only at the written request by client or authorized individual; receive considerate and respectful care in regard to self and property.

• Be given information regarding your anticipated transfer of your home health care services to another facility and/or termination of services to you.

• Be advised, before care is initiated, of charges and policies concerning payment including, to the extent possible, insurance coverage and other sources for payment.

B. Patient Responsibilities

• Remain under a licensed physician’s care, when applicable, while receiving services.

• Give accurate and complete information about past illnesses, hospitalizations, allergies, insurance coverage and other issues pertaining to your receipt of services. You must also report any changes about the above to the agency staff. Contact the agency if you are hospitalized, cannot keep an appointment or have changes in address or phone number.

• Provide a copy of an advance directive, such as a living will or power of attorney if available.

• Provide requested insurance and financial information, and sign required consents and releases. Changes in insurance coverage should be brought to the attention of the agency to facilitate proper billing procedures.

• Assume financial responsibility for all services rendered either through third party payers or personal responsibility for services not covered by insurance. Accept the responsibility for any refusal of treatment.

• Abide by the agency policy, which restrict duties our staff may perform. Staff may not work for the agency clients privately on their time off.

• Participate in the development of and update of your home care plan with your family member or caregiver.

• Adhere to your developed/updated home care plan. Request further information concerning anything you do not understand.

• Cooperate with your physician and our staff by following instructions and by asking questions about directions and/or procedures you do not understand

• Provide a safe home environment in which your care can be given. It is expected that you will not take drugs which have not been prescribed by your attending physician, and that you will not complicate or endanger the healing process by consuming toxic substances during your home care admission.

• Treat the agency staff with respect and consideration. Voice complaints or concerns regarding staff or services to the supervisor and or the agency office.

C/O CHEST PAIN IF YES: