Agreement and Consent Forhealth Care Services

AGREEMENT AND CONSENT FORHEALTH CARE SERVICES

Patient's Name:______DOB: ______

Phone Number: (______) ______-______Gender (circle): M F

Address:______City:______TX

Zip: ______Parent‘sName: ______Physician: ______

Physician Phone: (______)______-______Emergency ContactNAME (living outside of home): ______

Relationship to patient: ______Emergency Phone Number: (______) ______-______

TYPE OF SERVICE (circle):

Occupational Therapy Physical Therapy Speech Therapy Skilled Nursing

1. TERMS OF AGREEMENT: By signing this agreement, and being the parent or legal guardian of the patient, I give my consent to KidsCare Home Health to furnish the services listed above to the patient. By signing this agreement, I agree that in the event that KidsCare Home Health staff is not available to provide the appropriate care, then attempts will be made to provide service with another employee or contractor. I have the right to refuse backup services, and if I do so then I am acknowledging that I am capable, willing and able to provide the necessary care for my child. This contract may be cancelled at anytime by me or KidsCare Home Health upon giving five days’ notice to the other party.

2. MEDICAL CONSENT AND AUTHORIZATION INFORMATION:The patient is under the care of a licensed physician and I agreethat representatives of KidsCare Home Healthshall not be liable for any act resulting from following physician’s orders. If nurses are provided, I authorize the nurses to perform services necessary for patient's care. I authorize any hospital or physician to furnish KidsCare Home Health, upon request, all records pertaining to the patient’s medical history, services rendered or medical information to any applicable insurance carrier, or payer source. Per HIPAA (Health Insurance Portability and Accountability Act of 1996) I give myconsent that any medical records/information, and any other information pertinent to the patient’s care may be faxed, mailed, electronically relayed, orally relayed, or relayed by courier as may be necessary in providing the best care possible. I alsoagree that patient medical records, financial records or any other records that may need to be shared for treatment purposes, payment purposes, health care or non-health care purposes may be shared as it pertains to the provision of clinical servicesand payment.I agree to receive text message updates on therapy services or communication needs from KidsCare Home Health. I authorize KidsCare Home Health to bill and collect payment for services rendered to my insurance provider (major medical, Medicaid or Medicare, or other). I agree to furnish to KidsCare Home Health all information pertaining to the patient's insurance benefits and keep KidsCare Home Health updated of any changes in coverage. IN THE EVENT THAT THERAPY SERVICES ARE DENIED, I AUTHORIZE KIDSCARE HOME HEALTH TO ACT ON MY CHILD’S BEHALF AS THE REPRESENTING AGENT FOR APPEALSAND/OR FAIR HEARINGS.

3. I HAVE RECEIVED COPIES AND UNDERSTAND THE FOLLOWING:

Clinical Supervision of Home CareNotice of Information and Privacy PracticePatient’s Bill of Rights

Standards of Ethical PracticeDrug TestingMedical Power of Attorney

Non-Discrimination PolicyPatient Grievance PolicyHome & Child Safety

Scope of ServicesKCHH’s Policy on Advance Directives/Living Will Report of Abuse, Neglect, & Exploitation

Individualized Emergency Prep plan

4. FINANCIAL RESPONSIBILITY:For Medicaid beneficiaries, KidsCare Home Health will begin services after the physician and payor approve services, and will not be held financially responsible. For all other beneficiaries, if my insurance declines coverage, I acknowledge I may be held financially responsible to KidsCare Home Health for 100% of the billable amount of services. I certify that I have received a copy of this agreement and I grant consent to KidsCare Home Health to provide services. I attest that all information presented regarding the medical history for the above-stated patient is true and correct to the best of my knowledge.

5.CONSENT TO RELEASE RECORDS:KidsCare Home Health will release a minor’s medical records to either of the minor’s parents or to the minor’s legal guardian if the parent or legal guardian requests a copy. If you would like for KidsCare Home Health to treat anybody else as the minor’s legal representative and release the minor’s medical records to that person upon his or her request (for example, a step-parent or grandparent), then please provide that person’s name and relationship to the minor below. By providing the information below, you represent that you are the minor’s parent or legal guardian and you have the legal authority to obtain, and consent to the release of, the minor’s medical records. You may revoke this consent at any time. This consent will automatically expire upon the earlier of the following: revocation in writing by you or the minor’s other parent or legal guardian, or when the minor turns 18.

Name of Person(s) who May Obtain the Patient’s Medical Record:

Relationship to Patient:

______

Signature of Parent/GuardianPrinted Name Relationship to Patient

______

KidsCare Home Health RepresentativePrinted NameDate