Client Intake Form

have been informed that Pink Heart Home Healthcare is my primary, home health agency and is licensed to provide home health services under a Plan of Care authorized by a nurse. I accept personal care and respite care from Pink Heart Home Healthcare and can call the Agency 24 hours a day regarding my health care at (571) 499-7402. This is not an emergency line. Call 911 in an emergency. It is the policy of the Agency to protect all clinical records against loss, defacement, tampering and used by un authorized persons. I authorize the agency to release medical information to my physician, the facility of my choice, payer source or accrediting/regulatory/consulting organizations, as appropriate. I authorize the release of the Plan of Care and Discharge Summary upon my transfer to another health care facility. Consent to Photography: I hereby consent for the Agency to take pictures of myself and treatment being done and consent to the release of those photographs for use in advertisement or public education regarding home health services or to insurance providers to document my medical condition.

I authorize benefits to be made in my behalf.

All Medicaid-covered services, including personal care and respite care and supplies, will be paid by Medicaid. I understand I may be liable for payment of services provided by anyone other than Ata&Ana Home Health Agency, while Ata&Ana Home Health Agency is rendering services.

I am responsible to inform the Agency if I change to an HMO or any coverage. I will pay any service or supply charge not reimbursed by my insurance company or Medicaid on a monthly basis. I will pay all charges incurred on a monthly basis if I do not have insurance coverage. If a claim is denied for home health services, Personal Care Services, or Respite Care Services which Ata&Ana Home Health Agency has submitted on my behalf I hereby elect not to appeal the denial myself, but I do hereby authorize Pink Heart Home Healthcare to resubmit the claim for me and represent me in any negotiations. I authorize the Agency to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

I understand that an RN will supervise all services. I understand the frequency of services. This frequency may change according to need.

I have received a copy and Explanation of my Patient Bill of Rights and the Rights of the Elderly, as appropriate. I have been notified of my right to voice a complaint and understand that I may first file a complaint with the Administrator or designee at (571) 499-7402. The investigation of the complaint will be initiated at least within 10 calendar days and resolved within 30 calendar days of receipt. I can contact the Complaint Unit to report a complaint at 1-(800)-995-1819 in the event that I need information or if I have a complaint. I can also mail a complaint to the Complaint Intake, Office of Licensure and Certification, Virginia Department of Health, 9960 Mayland Drive, Suite 401, Richmond, Va. 23233-1463 or fax your complaint to 1-(804)-527-4503.

I have received an information sheet on Advance Directives including Durable Don Not resuscitate (DDNR).

I understand that this is my right and responsibility to be involved in my care and that I will be informed as to the nature and purpose of any technical procedure. I have been informed what to do in an emergency/natural disaster. I have been informed verbally and in writing regarding Agency policy on abuse, neglect and exploitation, agency drug testing policy and hazardous waste disposal in home. I have been advised verbally and in writing the purpose and my rights pertaining to the collection of OASIS information and the OASIS Privacy Act. HIPAA- I have received a Notice of Privacy Practices and consent to the agency's use and/or disclosure of protected health information for payment, treatment and Agency's Health care operations.

1. Treated with courtesy, consideration and respect and is assured the right of privacy;
2. Assured confidential treatment of his medical and financial records as provided by law;
3. Free from mental and physical abuse, neglect, and property exploitation;
4. Assured the right to participate in the planning of the patient's home care, including the right to refuse services;
5. Served by individuals who are properly trained and competent to perform their duties;
6. Assured the right to voice grievances and complaints related to organizational services without fear of reprisal;
7. Advised, before care is initiated, of the extent to which payment for the home care organization services may be expected from federal or state programs, and the extent to which payment may be required from the patient;
8. Advised orally and in writing of any changes in fees for services that are the patient's responsibility. The home care organization shall advise the patient of these changes as soon as possible, but no later than 30 calendar days from the date the home care organization became aware of the change;
9. Provided with advance directive information prior to start of services; and Virginia Department of Health Office of Licensure and Certification Regulations for the Licensure of Home Care organizations
10. Given at least five days written notice when the organization determines to terminate services.

The DMAS (Medcaid) pays Pink Heart Home Healthcare to provide Personal Care and/or Respite Care to you. If you have a problem with these services you should contact Zahra Siahi, operations manager, at (571) 449-7402. If the staff at the agency is unable or unwilling to help you solve the problem, you may contact the Long Term Care Unit at DMAS by calling 804-225- 4222 or by mail at: DMAS-Long Term Care Unit, 600 East Broad Street, Suite 1300, Richmond, VA 23219.

The patients admitted to Pink Heart Home Healthcare have specific rights and responsibilities and are also expected to adhere to specific conduct as outlined in the agency policy. The responsibilities and conduct include, but are not limited to the following:

• Responsible for participation in the development of their Plan of Care.
• Responsible for asking questions when he or she does not understand aspects of their care and treatment.
• Responsible for providing a safe environment for home care staff.
• Responsible for following the Plan of Care established by their attending physician or RN.
• Responsible for giving accurate and comprehensive account of past medical history.
• Responsible for giving honest and truthful information relating to health problems.
• Responsible for notifying the home care staff if he or she will not be available for scheduled visits.
• Responsible to notify the agency of any change in condition.
• Responsible to treat agency staff with respect.

Procedure: (Copy given to patient/caregiver on admission)

The following procedure must be followed if patients fail to comply with patient conduct Policy:

1. Director of Skilled Services and Administrator will be notified.
2. An attempt will be made by the DOSS or administrator to resolve issued with the patient/caregiver.
3. The patient/caregiver will be given a five (5) day notice of discharge and the social worker will be notified.

("passenger"), by signing this agreement acknowledges that there are certain inherent risks involved in riding in a privately owned car driven by my personal care aid ("Automobile"). In consideration of being permitted to ride in Automobile driven by an employee from Ata&Ana Home Health Agency, the Passenger hereby releases, waives, and discharges Pink Heart Home Healthcare and the Personal Care Aid, its officers, employees, directors, and shareholders from all liability to Passenger, his or her spouse, legal representative, heirs, and assigns, for any and all loss or damage, and any person or property, even injury resulting in death of Passenger, whether caused by the active or passive negligence of Pink Heart Home Healthcare or its employees, while Passenger is riding in the Automobile.

Passenger realizes that riding in Automobile may entail risks including but not limited to loss or damage to personal property, injury or fatality, collisions, falling while getting in or out of Automobile, or falling while aboard Automobile. Passenger hereby voluntarily assumes full responsibility for these and all other risks, and the risk of bodily injury, death or property damage while in or around Automobile, whether due to the active or passive negligence of Company or otherwise.

I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while riding in Automobile, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have and that Iam not pregnant.

Passenger agrees to indemnify, defend, and hold harmless Pink Heart Home Healthcare from any and all actions, causes of action, claims, judgments, loss, liability, damage or cost (including attorney's fees) that may occur due to the presence of Passenger in or around Automobile or which result from the Passenger's use of Automobile, whether caused by the active or passive negligence of Pink Heart Home Healthcare or its employee.

This release shall be binding upon Passenger, Passenger's parents and/or guardians, and the Passenger's heirs, assigns, and successors in interest. This agreement may be enforced by Company along with its respective heirs, successors, and assigns. I have carefully read this agreement and fully understand its contents.

American Red Cross of the National Capital Region, American Red Cross: Phone: 703-584-8400. Mail to: 8550 Arlington Blvd., Fairfax, VA, 22031 for information about the nearest shelter or assistance in case of a natural disaster. Take all your medications with you if you have to leave your home. Call 911 for Medical Emergency. The agency RN has assigned you the following home health triage levels: (Please Check off)

Coordination of Care with Other Agencies: Identify other agencies or services involved in care of patient

Home safety check and instructions

The Home Environmental Assessment form helps the agency identify safety or health hazards in the home and the presence of adequate living arrangements for our patients.

S= Satisafctory
US= Unsatisfactory
NA= Not applicable