Community resources: - Christiana Care Health System

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PATIENT NOTIFICATION of SERVICE & FINANCIAL RESPONSIBILITYHome health agencies have a responsibility to advise patients, in advance, about the services ordered by the physician and the extentto which payment is expected from insurance carriers or other sources, including the patient. This information is listed below.Patient’s name ID SSNSubscriber nameEmployerInsurance name HIC GroupDeductible amountCo-insurance co-payOther insurance nameThe checks below ACKNOWLEDGE MY RECEIPT AND ACCEPTANCE OF THE DOCUMENTS LISTED. These documentshave been fully explained to me and I agree to be an active participant in my plan for care at home. Consent & Information form OASIS Privacy Rights Notice of Privacy Practices Patient Rights & ResponsibilitiesADVANCE DIRECTIVES: Check the following based on patient/caregiver report and professional review of content withpatient/caregiver:I have an Advance Directive in the form of: Living will. I have not executed an Advance Directive. Durable Power of Attorney. I want more information. The Advance Directive includes a Do Not Resuscitate. Information providedCopy obtained for agency? Yes No Document location:Physician has a copy? Yes No Physician name:Name of Durable Power of Attorney: Phone #:TRADITIONAL MEDICARE or MEDICAIDEligibility Requirements Your Payment Responsibility VNA’s Responsibility to Bill Services VisitsCheck each requirement asWill bill your insurance DisciplineNo charge for services.presented to the patient.company. You require intermittent skilled careSkilled NursingFrequency& Duration Your doctor determined your need for home care & certifies a plan of care for youPhysical Therapy You are essentially confined to your home for the following reasons:Occupational Therapy Absences from home are medically contraindicatedSpeech Therapy Absences from home are for medical treatment which cannot be provided in the home. Social Work Leaving the home is short in duration, infrequent, requires considerable taxing effort, Home Health Aidassistance of another person(s) and/or assistive device.Initial Visit ApprovalALL OTHER INSURANCESSkilled NursingType of Coverage Your Payment Responsibility VNA’s Responsibility to BillPhysical TherapyOccupational TherapySpeech TherapyManaged MedicareorManaged MedicaidCoinsurance (amount you will pay afterpaying your deductible)Copayments (set amount you pay for eachvisit for each medical service)Bill sent to your insurance carrier tocalculate your coinsurance and to tellthe VNA the stated amount ofcopayment that you must pay.Social WorkHome Health AideOther health insuranceprovidersAny and all deductibles, coinsurance and/orcopayments as written in your insurancecontract.Bill sent to your insurance carrier tocalculate your coinsurance and to tellthe VNA the state amount ofcopayment that you must pay.______________________________ _________________ __________________________________ ________________Patient signature Date Responsible person/legal guardian Date______________________________ _________________ ______________________________________________________Witness signature Date Printed name & relationship of responsible persona/legal guardian
Table of ContentsTable of Contents.....................................................................................................................................1How VNA can help you..........................................................................................................................2Patient bill of rights .................................................................................................................................3Take control of your health (speak up)....................................................................................................5Advance directives and do not resuscitate order (DNR).........................................................................7Disaster planning ..................................................................................................................................11Home safety ..........................................................................................................................................12Smoke detectors....................................................................................................................................13Fall prevention (Adapting your Home)..................................................................................................14Infection control....................................................................................................................................16Needle and lancet safety.......................................................................................................................17Pain management..................................................................................................................................18Notice of privacy practice.....................................................................................................................20Important information about your medicare.........................................................................................26FormsEmergency care plan – what to do in an emergency .....................................................................30Medication list.................................................................................................................................31Patient consent form........................................................................................................................32Patient notice of services & financial responsibility ...............................................Inside Back CoverCommunity resources.............................................................................................................Back Cover1
Page 1 and 2: Community resources:Delaware State
Page 3: One Reads Way, Suite 100 New Castle
Page 7 and 8: Patient bill of rightsHome care con
Page 9 and 10: Take control of your health (speak
Page 11 and 12: Advance directivesOnly you have the
Page 13 and 14: Do I have to write an advance direc
Page 15 and 16: Disaster planning (emergency prepar
Page 17 and 18: ClothingClean your eyeglass lenses
Page 19 and 20: Adapting your homeKitchen Yes NoIs
Page 21 and 22: Needle and lancet safetyIf you rece
Page 23 and 24: Use of cold in relieving painUse of
Page 25 and 26: How we may use and disclose medical
Page 27 and 28: Lawsuits and disputes. If you are i
Page 29 and 30: Changes to This noticeWe can change
Page 31 and 32: Your length of service from VNA and
Page 33 and 34: Condition Call VNA or physican Call
Page 35 and 36: Medication listName _______________

Community resources: - Christiana Care Health System

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