Assignment of Benefits: I request that payment of the authorized benefits on my behalf be made to the Agency. I understand that I will be responsible for any co- payments, deductibles, or any amounts due after payment of benefits on my behalf by any and all third party payers. I understand that I must keep the home health agency informed of any changes that occur that may jeopardize my qualifying for these or any other benefits I may be entitled to. Agency accepts assignment from Medicare, Medicaid, PASSPORT, and Senior Options as payment in full.
Receipt and review of client handbook: I certify that I have received and understand the information contained in the Patient Hand book. This handbook contains important information regarding my rights and responsibilities as a client, the Statement of Patient Privacy Rights, Notice about Privacy Act Statement - Health Care Records, the HIPPA Statement of Patient Privacy Rights, Nondiscrimination Policy, Section 504 Notice of Program Accessibility/ Translation Assistance, Information about Safety and Infection control, Advance Directives, Payment for Home Care Services. Grievance Procedure, the State Complaint Hotline Number, and payment rates for services.
Release of information: I give my permission to Summit Orthopedic Home Care to release to or receive from hospitals, physicians, other agencies including regulatory or accrediting agencies, and I or other persons involved in my care all medical records and information important to my care, including the presence or absence of communicable disease. I authorize agencies to release medical and other related information (unless I indicate otherwise in writing) to above and social/health care agencies, contracted agencies, case management agencies, laboratories, family members, and medical equipment / supply vendors whose services may be required in conjunction with the services provided.
Advance Directives: I understand it is the policy of Summit Orthopedic Home Care to provide services to all persons without regard to whether they have executed any advance Directives. I understand that my decision regarding Advance Directives can be changed at any time. I will notify Summit Orthopedic Home Care, My physician(s), and my family should I wish Jo make changes. I would like to indicate the following at this time: