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Sus quejas y problemas son importantes para nuestra Agencia. Vamos a tener plenamente en cuenta cualquier problema o queja y hacer un esfuerzo para resolver el problema de una manera conveniente. Nosotros le aseguramos que tendrá la oportunidad de expresar sus quejas y podrá recomendar cambios a los servicios y/o pólizas sin ningún tipo de discriminación, coerción, represalias o interrupción injustificada de los servicios o de de cualquier forma por parte de la Agencia.

Si usted tiene una queja, por favor:

1. Presentar la queja, ya sea verbalmente o por escrito al Administrador o Supervisor de Enfermeria. Si usted llama después de las horas normales de trabajo, usted será contactado por el Administrador en el siguiente día hábil. El nombre, direccion y numero de telefono del Administrador es:
2. El Administrador o Supervisor de Enfermeria se pondrá en contacto con usted o su representante, y harán todos los esfuerzos para resolver la queja a su satisfacción. Ellos documentarán todas las actividades involucradas en el reclamo / queja / preocupación, la investigación, el análisis y resolución de la queja. Usted recibira una respuesta por escrito departe del Administrador de la Agencia dentro de 10 dias y la queja sera resuelta dentro de 30 dias.
3. Si la queja noes resuelta a su satisfaction, usted puede pedir al Adminstrador que presente su queja presentar su queja a la Junta de Directores de la Agencia.
4. Por favor, tenga en cuenta que usted puede presentar una queja con la Linea Estatal “gratis” al 1-800+252-4343. El horario de operaciones es de 8:00 AM a 5:00 PM. Despues de horario normal de oficina, por favor dejar un mensaje.

Annie Tchinjo, Administrator
My Home Nurses LLC
924 East Hyde Park Blvd., Unit 3W
Chicago, IL 60615
708+801-8662
GRACIAS POR COMPARTIR SUS PREOCUPACIONES CON NOSOTROS

Statement of Purpose

It is anticipated that observance of these rights and responsibilities will contribute to more effective care and greater satisfaction for the patient as well as the staff. The rights will be respected by all personnel and integrated into all Home Health Care programs. A copy of these rights will be given to patients and their families or designated representative. If a patient designates a representative, you must provide that representative with written notice of the patient’s rights and responsibilities within 4 business days of admission.If the patient or his/her designated representative is unable to read the Bill of Rights and Responsibilities, it will be read to them. If the patient or his/her representative does not speak English, a copy of theserights will be provided in a language that is understood. The patient or his/her designated representative has the right to exercise these rights. In the case of a patient adjudged incompetent, the rights of the patient are exercised by the person appointed by law to act on the patient's behalf. In the case of a patient who has not been adjudged incompetent, any legal representative may exercise the patient's rights to the extent permitted by law.

The Patient has the right:

1. To be fully informed in writing and knowledgeable of all rights and responsibilities before providing pre-planned care,and as any changes occur during episodes of care,and to understand that these rights can be exercised at any time.
2. To receive appropriate care without discrimination in accordance with physician orders.Section 1557 of ACA: Discrimination is prohibited on the basis of race, color, national origin, sex, age, or disability
3. To receive all services outlined in the plan of care
4. To choose a healthcare provider, including choosing an attending physician.
5. To request services from the Home Care Agency of their choice and to request full information from their agency before care is given concerning services provided, alternatives available, licensure and accreditation requirements, organization ownership and control.
6. To be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modification to the plan of care.
7. To be informed that the patient’s family or guardian may exercise the patient’s rights when the patient has been judged incompetent.
8. To participate in the development and periodic revision of the plan of care/service.
9. To access to his/her medical recordsand to confidentiality and privacy of all information contained in the patient record and of Protected Health Information according to HIPAA, Federal, State and Accreditation requirements.
10. To information necessary to refusetreatment within the confines of the law and to be fully informed of the consequences.
11. The patient has the right to participate in, be informed about, and consent or refuse care with respect to:
• Completion of all assessments
• The care to be furnished, based on the comprehensive assessment
• Establishing and revising the plan of care
• The disciplines that will furnish the care
• The frequency of visits
• Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits
• Any factors that could impact treatment effectiveness
• Any changes in the care to be furnished
12. To treatment with utmost dignity and respect by all agency representatives, regardless of the patient's chosen lifestyle, cultural mores, marital status, political, religious, ethical beliefs, having or not having executed an advance directive and source of payment without regard to race, creed, color, sex, age or handicap.
13. To have his/her property and person treated with respect, consideration and recognition of patient dignity and individuality.
14. To receive and access services consistently, with continuity, and in a timely manner from the agency to his/her request for service.
15. To receive information about the care/services covered under the Medicare Home Health benefit, if applicable.
16. To an individualized plan of care and teaching plan developed by the entire health team including the patient and/or family.
17. To receive information about the scope of services that the HHA will provide and specific limitations on those services.
18. To be informed of anticipated outcomes of service/care and of any barriers in outcome achievement.
19. To be informed of patient/patient rights regarding the collection and reporting of OASIS information. OASIS information will not be disclosed except for legitimate purposes allowed by the Privacy Act.
20. To be advised on the agency’s policies and procedures regarding the disclosure of clinical records.
21. To be informed within a reasonable time of anticipated termination of service or of plans for transfer to another health care facility/provider and the reason for termination/transfer of services.
22. To be informed verbally and in writing and before care is initiated of the organization's billing policies and payment procedures and the extent to which:
• Payment may be expected from Medicare, Medicaid, or any other federally funded or aided program known to theorganization.
• Payment may be expected from any other third-partypayer
• Charges for services that will not be covered by Medicare.
• Charges that the individual may have to pay
• Any changes in the information provided in this section when they occur. The Agency must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit
23. To be able to identify visiting staff members through agency generated photo identification
24. To be informed orally and in writing of any changes in payment information as soon as possible, but no later than 30 days from the date that the organization becomes aware of the change
25. To access necessary professional services 24 hours a day, 7 days a week
26. To be referred to another agency if he/she is dissatisfied with the agency or the agency cannot meet the patient's needs
27. To be informed of any financial benefits when referred to an organization.
28. To education, instruction and a list of requirements for continuity of care when the services of the agency are terminated.
29. To be free from mistreatment, neglect or verbal, mental, sexual and physical abuse including injuries of unknown source, and misappropriation of patient property.
30. To know that the agency has liability insurance sufficient for the needs of the agency.
31. To be advised that the agency complies with Subpart 1 of 42 CFR 489and receive a copy of the organization's written policies and procedures regarding advance directives, including a description of an individual's right under applicable state law to formulate advanced care directives without fear of reprisal whether or not an advance directive is prepared and to know that the agency will follow the patient’s requests regarding the advance directive in providing care.
32. To receive advance directives information prior to or at the time of the first home visit, as long as the information is furnished before care is provided and to know that the Hotline number 1-800+252-4343 may be used to lodge complaints regarding the implementation of the Advance Directive requirement.
33. To voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect of property or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal and to know that grievances will be resolved,and the patient notified of the resolution within 30 days.
34. To be advised of the toll-free home health agency hot-line for the State of Illinois and the purpose of the hotline to receive complaints or questions about the organization. The State of Illinois Home Health Hotline is 1-800+252-4343. The number is operated 8:30AM to 5PM daily to receive complaints or questions about local Home Health Agencies. You may also register complaints in writing to:
    
    Central Complaint Registry
    Illinois Department of Public Health
    525 W. Jefferson Street
    Springfield, IL 62761.
    
    
35. To not be denied equal opportunity because they or their family are from another country, because they have a name or accent associated with a national origin group because they participate in certain customs associated with a nation origin group, or because they are married to or associate with people of a certain national group.
36. To be informed of the toll-free elder abuse hot-line 1-866+800+1409 used to report abuse, neglect or exploitation.
37. To be informed of the toll-free child abuse hot-line 1-800+252-2873.
38. To be provided language assistance using competent bilingual staff, staff interpreters, contracts, formal arrangements with local organizations providing interpretation, translation services, or technology and telephonic interpretation services.
39. To be informed of the contact information for the agency Administrator:
    
    • Name:Annie Tchinjo, RN
    • Address:5113 S Harper Ave 2c, Chicago, IL 60615
    • Phone number:708+801-8662
    
    
40. To be advised of the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that serve the area where the patient resides:
    
    Agency on Aging
    Center for Independent Living
    Protection and Advocacy Agency
    Aging and Disability Resource Center
    Quality Improvement Organization
    
    
41. To be provided information on discharge policies and procedures.
42. To have a confidential clinical record; access to or release of patient information and clinical records per the agency’s policies and procedures.
43. To receive proper written notice, in advance of a specific service being furnished, if the Agency believes that the service may be non-covered care; or in advance of the Agency reducing or terminating on-going care.

The Patient has the right:

1. To provide, to the best of his/her knowledge, accurate and complete information about: a.Past and present medical histories.
   b.Unexpected changes in his/her condition.
   c.Whether he/she understands a course of action selected.
   
2. To follow the treatment recommended by the particular handling of the case.
3. For his/her actions if he/she refused treatment or does not follow the physician’s orders.
4. For accruing that the financial obligations of his/her health care are fulfilled as promptly as possible.
5. To respect the rights of all staff providing service.
6. To notify the agency promptly in advance of an appointment or visit you must cancel.
7. To become independent in care to the extent possible, utilizing self, family and other sources.
8. To pay for care or services not covered by 3rdparty payers.
9. To comply with the rules and regulations established by the agency and any changes subsequent to the rules.

Emergencies include natural and manmade disasters. This may include hurricanes, tornadoes, earthquakes, severe weather or other natural disasters or it may include manmade disasters such as bio-terrorism, Terrorism, Radiation, Chemical Spills, Nuclear Accidents and Hazardous Material.

We are faced with many types of emergency situations that may cause an interruption in services.

In the event you are faced with a natural disaster, inclement weather,and/or other emergency situation,to ensure the highest level of patient care & continuity of services,it is the policy of the agency that a client immediately callthe agency to adviceof the emergency situation. Please utilizethe following to contact the agency:

AGENCY PHONE NUMBER: 708+801-8662

If you choose to evacuate during an emergency, you must take provisions with you. The following suggested items will make your temporary stay more comfortable:

• Foods that do not need cookingand Drinking water(1 gallon per person per day)
• Special dietary food if required
• Identification, valuable papers and photos, including medical information.
• Personal hygiene items, such as: soap, deodorant, shampoo, toothbrush, toothpaste, aspirin, antacid, incontinent supplies,washcloth, towels etc.
• Utensils, such as: manual can opener, disposable plates, cups, forks, knives, spoons, napkins.
• Prescription medicines, written prescription for refills & list of medications
• Books, magazines, cards, toys, and games for adults and children.
• Infant care items such as formula, food, disposable diapers and toys.
• Battery operated radioflashlight & lantern, extra batteries & earphones.
• First aid kit including: betadine solution, bandages, adhesive tape, Band-Aids, bandages, safety scissors, non-prescription medicines.
• Personal aids such as: eyeglasses, hearing aids & prosthetic devices.
• Change of clothing and rainwear; Sleeping bag or blanket, sheet & pillow.

REMEMBER: ALL ALCOHOLIC BEVERAGES, ILLEGAL DRUGS, PETS, AND WEAPONS ARE PROHIBITED WITHIN EMERGENCY PUBLIC SHELTERS. For more information, see the community reference pages in your telephone directory, or call:

Cook County Emergency Management Office
69 W. Washington Street
Chicago, IL 60602
708+865-4766

Como paciente de servicios de salud en el hogar, usted tiene los derechos de privacidad listados a continuación.

1. Usted tiene derecho a saber por quénosotros necesitamos hacerle preguntas.
   La ley requiere que nosotros recaudemos la informaciónsobre su salud para asegurar:
   1. que usted obtenga cuidados de salud de calidad, y
   2. que los pagos para los pacientes de Medicare y Medicaid sean los correctos.
2. Usted tiene derecho a que la informaciónsobre el cuidado de su salud se mantenga en forma confidencial. Puede ser que le pidamos que nos de informaciónsobre usted para poder saber quétipo de servicios de cuidado de la salud en el hogar es el mejorpara usted. Nosotros mantenemos todo lo que sabemos sobre usted en forma confidencial. Esto significa que solo aquellos que estánlegalmente autorizados a saber, o que tienen una necesidad médica de saber, veránsu informaciónpersonal de salud.
3. Usted tiene derecho a rehusarse a contestar preguntas. Puede ser que nosotros necesitemos su ayuda para recaudar la informaciónsobre su salud. Si usted elige no contestar, nosotros completaremos la informaciónlo mejor que podamos. No es necesario que usted conteste todas las preguntas para obtener los servicios.
4. Usted tiene derecho a revisar su informaciónpersonal de salud.
   1. Nosotros sabemos lo importante que es que la informaciónque obtenemos sobre usted sea correcta. Si usted cree que cometimos un error, danos que lo corrijamos.
   2. Si no estásatisfecho con nuestra respuesta, usted puede pedirle a Centros de Servicios de Medicare y Medicad, la agencia federal de Medicare y Medicad, que corrija su información.
   Usted le puede pedir a Centros de Servicios de Medicare y Medicadver, revisar, copiar o corregir la informaciónPersonalde su salud que la agencia Federal mantiene en su sistema de archivos OASIS de la Agencia de Servicios de Salud en el Hogar. Véase la parte de atrásde este aviso y obtenga la INFORMACION PARA PONERSE EN CONTACTO. Si usted quiere una descripciónmásdetallada sobre sus derechos de privacidad, lea la parte de atrásde este aviso: DECLARACION DEL ACTA DE PRIVACIDAD -ARCHIVOS DEL CUIDADO DE LA SALUD.

Para Pacientes que no tienen la cobertura de Medicare o Medicaid

1. Como paciente de servicios de la salud en el hogar, hay algunas cosas que usted debe saber sobre nuestra recolección de información personal sobre el cuidado de su salud.
   
   1. Los gobiernos Estatales y Federal supervisan el cuidado de la salud en el hogar para asegurarse que nosotros proveemos dichos servicios de calidad, y que usted, en particular, obtiene servicios de cuidado de la salud en el hogar de calidad.
   2. Nosotros necesitamos hacerle preguntas porque la ley requiere que recolectemos la información relacionada a su salud para asegurar que usted obtiene servicios para el cuidado de la salud de calidad.
   3. Nosotros haremos su información anónima. De ese modo, Centros de Servicios déMedicare y Medicaid, la agencia Federal que supervisa esta agencia de servicios de salud en el hogar, no puede saber que esa información le correspondea usted.
2. Nosotros mantenemos todo lo que sabemos sobre usted en forma confidencial.

1. Admitting Staff Checklist
2. Homebound Determination Form
3. Consent for Treatment and Financial Agreement (in DUPLICATE)
4. Authorization Agreement and Acknowledgements (in DUPLICATE)
5. Advance Directive / HIPAA Acknowledgement (in DUPLICATE)
6. Authorization for Release and Disclosure of Protected HealthInformation
7. Patient Rights and Responsibilities (in DUPLICATE)
8. Medicare ID
9. Patient Emergency and Contact Information (in DUPLICATE)
10. Patient Acknowledgment –Receipt of Patient Information Booklet
11. Home Safety Assessment (in DUPLICATE)
12. Notice of Privacy Rights
13. Additional Forms

Advance Beneficiary Notice of Non-Coverage (ABN)
Physician’ Order/Verbal/Telephone Order
Home Health Change of Care Notice (HHCCN) (in DUPLICATE)
Skilled Nurses Notes
Home Health Aide Plan of Care (in DUPLICATE)
Discharge
Coordination of Care
Home Health Change of Care
Post Admission Client Satisfaction Survey
60 Day Summary Report

Based on the patient responses, this patient has been determined to be homebound. The patient has been given an explanation and by signing this form understands the definition of homebound and agrees to comply with the homebound requirement. The patient understands and agrees that once his /her condition changes and he /she is able to leave the home more often for longer periods of time for non-medical purposes or begins to drive, that he / she will contact the Agency immediately. The patient also understands the Agency must insure that all Medicare and Medicaid patients are homebound to qualify for home care services and that the Agency must adhere to all federal regulations atall times with no exceptions. Failure to comply with homebound requirements may result in patient liability for payment of services as allowed by federal law.

If the patient does not meet Homebound Criteria, call the Agency office immediately for further instructions.

CHARGE FOR SERVICES: Your initial services from the Agency will include the following services and initial frequency of visits and charge per visit if private insurance or private pay.Payer for services: .

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PATIENT LIABILITY FOR PAYMENT: You have the right to be advised, before care is initiated, of the extent to which payment for services may be expected from Medicare or other sources and the extent to which payment may be required from you, the patient. We are advising you, orally and in writing, about the cost of items and services to be provided: Medicare part A or part B: Services provided are paid in full by Medicare. No cost to patient. HIC Number

Medicare Part B Outpatient; Patient is responsible for the annual deductibleand 20% co-payment for all charges for PT, ST. OT series which is per visit.You will receive a bill monthly for charges incurred and not covered by Medicare. Medicaid: Services provided are paid in full by . As the patient, you and your representative, if any, will be notified of any change in the charges for items or a service provided through Medicare, Medicaid or other relevant Federal Programs both orally and in writing BEFOREthe next visit.Please Circle one of the following: Black Lung Veteran Administration, Worker’s Compensation,or Private Insurance. Your Insurance Company is This insurance Company covers % of the charges. You are responsible for per visit, which is the balance after insurance pays. The deductible amount of will be billed to you. You will be responsible for charges related to the services provided to you by this agency. Charges related to supplies used in providing care to you before these charges are implemented. Payment if rendered with my signature below. This assignment shall not extinguish or diminish the patient’s obligation to paythe full fee to the company for services rendered but the patient shall receive credit for all sums collected pursuant to the agreement. If the enrolled patient is in another insurance plan of HMO, it is the patient’s responsibility to notify the Agency or the patient will be held responsible for payment.

PATIENT’S RIGHT/EMERGENCY PLAN/COMPLAINT PROCEDURE: I have been informed of my rights and received a copy of the Client’s Bill of Rights prior to the start of care procedure, “Advanced Directives, Emergency Plan, Out-of-Hospital, Do-Not-Resuscitate, Patient’s Conduct & Responsibilities, Abuse/Neglect/Exploitation”. I have been allowed to participate in planning my care and have received a copy of the State’s Toll Free Home Health Agency Hotline Number forIllinois, 1-800+252-4343which receives complaints or grievances 24hours aday, seven days a week. .

CONFIDENTIALITY: It is our policy to protect all clinical records against loss, defacement, tampering and use by unauthorized person(s). All patient identifiable information in the clinical record, including OASIS data, remains confidential and is notreleased to the public. OASIS data will be electronically transmitted to the state. The patient’s written consent shall be required for the release of medical information to persons not otherwise authorized by law (federal and state) to receive this information. Authorized persons who may review the clinical record include surveyors, physicians, Centers for Medicare and Medicaid Services (CMS), and external and internal auditing personnel.

RELEASE OF RECORDS: I understand the agency policy with regard to confidentiality and release of records prohibits access to my records by persons other than personnel involved in care. I therefore give written consent for release of medical records to health care providers in my treatment care.

The patient has received written information regarding their right to make healthcare decisions.

I GRANT permission to the employees of My Home Nurses LLC herein referred to as "the Agency" to render skilled nursing care and other ancillary skilled professional home health services as required and ordered by my physician.

I ACKNOWLEDGE that the Agency has notified informed and explained to me the PATIENT BILL OF RIGHTS. I have received information on Advance Directives, Directives to Physician, Durable Power of Attorney for Home Health Care, and Out of Hospital DNR orders, the services to be provided, the supervision of the services, and charges for services rendered will bethe responsibility of the patient/family to pay.

I AUTHORIZE the Agency to release any medical information requested by representatives of local, state or federal agencies, accrediting bodies, insurance companies, or other organizations or entities as may be required by said representatives for payment of claims out of this home health care which are due. The agency has notified me of the Policies and Procedures regarding Disclosure of Clinical Records.

I REALIZE that Agency staff may not be present in my house at all time and I, my caregiver or legal guardian will assume responsibility for my care when agency staffs are not present.

I UNDERSTAND that the Agency does not routinely perform drug testing on its employees but may do so at our discretion using urine samples.

I UNDERSTAND that the Agency will notify me in writing and orally, no later than 30calendar days from the date they become aware of charges not covered by Medicare or other sources.

I UNDERSTAND that in the event of an emergency during which the Agency cannot meet my needs, the Agency can transfer me to another Agency that can provide the care I require.

I CERTIFY that no Medicare home health services are being provided to me and I am not enrolled to any HMO/PPO organization.

I FURTHER UNDERSTAND that Agency employees may not be employed by me without first compensating the Agency $1100.00 or employee’s annual wages, which is even greater.

INSURANCE ASSIGNMENT: In consideration of any services rendered, I hereby assign and transfer to the Agency any benefits payable to or for my benefit under the rules and regulations prescribed by Medicare. I agree to cooperate, aid and assist the Agency in the process of billing Medicare for these services. I certify that no home health agency is currently providing home health care and understand the misrepresentation of this fact shall cause me to be liable financially for care rendered by the Agency. If home health services provided by another home health agency in the past, I have requested discharge from those services prior to my start of care date with this Agency.I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request that payment of Client benefitsin my behalf are made directly to the Agency.

I HAVE BEEN INFORMED of the Agency’s policies for resuscitation, medical emergencies and accessing 911 services. (EMS)

I AM AWARE that a Registered Nurse will be supervising my care and if I have complaints regarding services rendered, I am to contact the RN in charge of my care.

I HAVE BEEN INFORMED of my rights and that I may file complaints about the Agency with the Illinois Home Health Hotline at 1-800+252-4343, during regular business hours. After hours/ holiday calls will be answered by machine and responded to the next business day.

CONSENT TO RECEIVE SERVICES: I, acknowledge that the Agencyhas provided me with information which indicates that I may accept or reject any medical treatment, including any particular care specified:

• Living Will or Out of Hospital Do Not Resuscitate (DNR)
• Statutory Power of Attorney for Health Care decisions
• Advance Directives in Illinois–A Health Care Directive
• HIPAA/Home Care Privacy Rights

I also understand that it is my responsibility to ask question about the information provided by the Agency. They have offered to provide a copy of the state’s illustrative forms under state law if I request. I have also been advised to consult with my physician, lawyer, family, clergy, social worker or other qualified personnel for additional information or contact with a lawyer should I need assistance in changing the forms to reflect my treatment wishes or in executing a living will or statutory Power of Attorney for health care decisions.

I understand that this Agency will honor the advance directives and is willing and able to provide any procedure specified on the advance directives.

I understand that the fact that I have or have not signed a living will or Statutory Power of Attorney for Home Care decisions does not affect the medical treatment and home care to be provided by the Agency. I understand that it is the Agency’s written policy to fully comply through its healthcare providers with the terms of a patient’s Living Will or Statutory Power of Attorney for Healthcare decisions to fullest extent permitted by state statutory Power of Attorney for Healthcare decisions to fullest extent permitted by state law.

I have been given an explanation and acknowledge receipt of the HIPAA PRIVACY RIGHTS. I understand that I may contact the Agency at any time for questions or concerns.

Patients have the right to give adequate notice concerning the use/disclosure of their PHI on the first date of service delivery, or as soon as possible after an emergency. The Privacy Rule grants patients new rights over their PHI, including the following:

1. Receive a Privacy Notice at the time of the first delivery of service,
2. Restrict use and disclosure, although the covered entity is not required to agree,
3. Have PHI communicated to them by alternate means and at alternate locations to protect confidentiality,
4. Inspect, correct and amend PHI and obtain copies, with some exceptions,
5. Request a history of non-routine disclosures for six years prior to the request, and,
6. Contact designated persons regarding any privacy concerns or breach of privacy within the facility or at HHS.

Federal law requires that this agency provide the above information.

I, , hereby authorize My Home Nurses LLC (hereafter collectively referred to as “Agency”) to use and disclose in any form or format, acopy of records concerning (PRINTclient/patient) but only as follows. A copy of this signed, dated Authorization shall be as effective as the original. Agency may use and disclose the following information.

For the purpose(s) of (be specific):

The undersigned does hereby release, hold harmless and agree to indemnify Agency, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this authorization. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this authorization remains effective until Agency is in actual receipt of a signed revocation or until the records retention period required under federal and state law has expired and the records have been destroyed; that I have the right to revoke this authorization at any time, provided I do so in writing; that I have been given an opportunity to ask questions; that I have received a copy of the signed authorization; that I may inspect a copy of my protected health information to be used or disclosed under this authorization; that the Agency has not conditioned provision of services to or treatment of me upon receipt of this signed authorization; and that I may refuse to sign this authorization.

The Patient has the Responsibility:

1. To provide, to the best of his/her knowledge, accurate and complete information about:
1. Past and present medical histories.
2. Unexpected changes in his/her condition.
3. Whether he/she understands a course of action selected.
2. To follow the treatment recommended by the particular handling of the case.
3. For his/her actions if he/she refused treatment or does not follow the physician’s orders.
4. For accruing that the financial obligations of his/her health care are fulfilled as promptly as possible.
5. To respect the rights of all staff providing service.
6. To notify the agency promptly in advance of an appointment or visit you must cancel.
7. To become independent in care to the extent possible, utilizing self, family and other sources.
8. To pay for care or services not covered by 3rdparty payers.
9. To comply with the rules and regulations established by the agency and any changes subsequent to the rules.

I, ,have received the following information from the Representative of My Home Nurses LLC prior to the beginning of care:

Patient Information Booklet, which includes:

1. Service Outline
2. Emergency Contact Information
3. Non-Discrimination Polices
4. Patient Rights and Responsibilities
5. Patient Grievance
6. Abuse, Neglect, and Exploitation; Abuse and State Hotline numbers
7. Home Health Aide Duties
8. Accident Prevention
9. Notice of Privacy/Privacy Act Statement
10. Medication Information
11. Fire Safety
12. Biomedical Waste Disposal
13. Emergency Instructions, Resource numbers and Disaster Preparedness
14. Advance Directive Information Summary
15. Patient Privacy Rights/HIPAA

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. Below is a description, including at least one (1) example, of the types of uses and disclosures that the above organization is permitted to make for each of the following purposes: treatment, payment and health care operations.
   Disclosures to other health care providers, including, for example, to patients' attending physicians. Submission of claims and supporting documentation including, for example, to organizations responsible to pay for services provided by the organization. Disclosures to conduct the operations of the organization, including, for example, sharing information to supervisors of staff members who provide care to patients.
2. Below is a description of each of the other purposes for which the organization is permitted or required to use or disclose protected health information without an individual's written consent or authorization.
   To patients, incident to another permitted use or disclosure, by agreement, to the Secretary of the U.S. Department of Health and Human Services, as required by law, for public health activities, information about victims of abuse, neglect or domestic violence, health oversight activities, for judicial and administrative proceedings, for law enforcement proceedings, about decedents, for cadaveric organ, eye or tissue donation, for research purposes, to avert a serious threat to health or safety, for specific government functions, to business associates of the organization, to personal representatives, de-identified information, to workforce members who are victims of crimes, to workers' compensationprograms, for involvement in the individual's care and for notification purposes, with the individual present, for limited uses and disclosures when the individual is not present, and for disaster relief purposes.
3. Other uses and disclosures, such as disclosure of psychotherapy notes, use of protected health information for marketing activities and the sale of protected health information, will be made only with the individual's written authorization and the individual may revoke such authorization.
4. The organization may contact the individual to schedule visits and for other coordination of care activities.
5. The individual has the right to request further restrictions on certain uses and disclosures of protected health information, but the organization is not required to agree to any requested restriction(s), except disclosures must be restricted to health plans if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the protected health information pertains solely to a health care item or service for which the individual or person other than the health plan on behalf of the individual has paid the organization in full.
6. The individual has the right to receive confidential communications of protected health information, the right to inspect and copy protected health information, the right to amend protected health information, the right to receive an accounting of disclosures of protected health information and the right to obtain a paper copy of this Notice from the organization upon request.
7. The organization is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information and to notify affected individuals following a breach of unsecured protected health information.
8. The organization is required to abide by the terms of this Notice currently in effect.
9. The organization reserves the right to change the terms of its Notice and to make the new notice provisions effective for all protected health information that it maintains. Individuals may obtain a revised copy of this Notice upon request.
10. Individuals may complain to the organization and to the Secretary of the U.S. Department of Health and Human Services if they believe their privacy rights have been violated. Complaints should be directed to (Name or title of person) at the organization at the following telephone number: Individuals will not be retaliated against for filing a complaint.
11. For further information, individuals should contact (Name or title of person) at the organization at the following telephone number: .
12. This Notice is in effect as of .
13. My signature below is an acknowledgement that I have received a copy of this notice.

Documentation of good faith efforts to obtain the patient's signature if unable to obtain

Your home health care is going to change. Starting on DC Date TBDyour home health agency will change the following items and/or services for the reasons listed below.

Read the information next to the checked box below.Your home health agency is giving you this information because:

If you have questions about these changes, you can contact your home health agency and/or the doctor who orders your home care.

You cannot appeal to Medicare about payment for the items/services listed above unless you both receive them and a Medicare claim is filed.

Please sign and date below to show that you received and understand this notice. Return this signed notice to your home health agency in person or by mailing it to them at the address listed at the top of this notice.