Admission Service Agreement Form for Home Health
| MPN | 3529-3P |
|---|---|
| Brand | Briggs Health Care |
| Packaging | 100 per pack |
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This two-page, three-part form is the consent for care or service. It can be used to document if the patient has:
A Legal or Selected Representative
Liability for Payment
Assignment of Benefits
Consolidated Billing - Supplies (for Medicare Home Health patients only)
This form also documents the acknowledgement of information given to the patient for:
Advanced Directives
Patient s Rights and Responsibilities
Statement of Patient Privacy Rights and Privacy Act Statement - Health Care Records
Basic Home Safety
Emergency Planning
Infection Control
Agency's Transfer/Discharge Policy
The Admission Service Agreement requires signatures from the patient and/or their legal representative (if any), admitting clinician and the financial guarantor if different from the legal representative. This form works in conjunction with the Welcome to Home Care Services Booklet (Item #3400B).
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