PATIENT SERVICE AGREEMENT / MSP / ACKNOWLEDGEMENT RECEIPT & EXPLANATION

I. Request for Admission & Authorization to Treat & Release of Information

I hereby request admission to Lorian Health (Lorian), and I consent to such care and treatment as is ordered by my physician through the home health program. I authorize release of all medical records necessary for reimbursement, care coordination purpose and for licensing/accreditation bodies.

II. Financial Responsibility Statement

Medical Statement. Assignment of benefits: I hereby request payment and assign any benefit due to me under the terms of any policy or policies and/or Title XVIII of the Social Security Act that may cover my Home Health visits, to be paid directly to Lorian for services rendered, but not to exceed the regular charges, or the maximum amount allowed by Medicare, or Payor for the care given. If a copay is required such charges will be documented on documents 57. Further, I understand that if at any point Medicare regulations or specific Payor criteria determine skilled services are no longer covered, I will be immediately informed and will be given the option to discharge services or make other payment arrangement (see documents 57). When this occurs the financial data previously given will be canceled and new financial data will be filled out determining the new payment source and amount (see documents 57). Medicare/Medi-Cal reimbursement is accepted as full payment; however, I agree to make a good faith effort in notifying Lorian of any change in insurance payor source as soon as possible. Upon admission I am responsible for notifying Lorian or anytime during my service with Lorian if I am to receive, or Have received, any other services outsourced by another provider, i.e. Outpatient Therapy, Medical Supplies Provider, or another Home Health Agency. If I do not inform Lorian that I am receiving outsourced services by another provider, I understand that I may be held responsible for any outstanding payment due to the servicing provider(s). If i have been fully transparent of information that i am aware of and no fault of my own have not informed Lorian, Lorian in return will never pursue me for losses incurred by Lorian for services on my behalf. If the aforesaid agreement is breached and it is found that I have not complied with my obligations, Lorian will hold me responsible at a rate of $347.00 per visit upon the date that I am found negligible of the aforesaid agreement.

III. I hereby acknowledge receipt, explanation, and understanding of the

following:

Clinician has reviewed/instructed me on the following checked boxes: ____________ Clinician Initial _________ Patient Initial

□ 24 Hour Home Health Hotline – Inside front cover

□ Patient Rights & Responsibilities – page 1

□ Health Info Portability and Accountability Act (HIPAA) – page 4

□ Advance Directives and Patient Education Packet – page 10

□ Basic Home Safety & Waste Disposal Tips – page 13

□ Home Environment Safety Evaluation – page 47

□ Clarification of Homebound Status – page 48

□ Procedure for Requests and Complaints – page 49

□ Photo Consent Form – page 50

□ Wireless Home Monitoring Program Physician Authorization – page 51

□ Financial Responsibility & Payment Expectation (Section II above & Documents 57).

Patient Name ______________________________________________ Patient ID ____________________________________

I have reviewed and agreed to everything above.

Patient Signature ____________________________________________ Date ________________________________

Witness Name & Title _________________________________________ Date ________________________________

I have reviewed the above information with the patient and confirmed they fully understand everything.

Witness Signature ___________________________________ __________ Title ________________________________

Your Plan For Home Health

What is your goal that home heath can assist you with?

Planned home health team members:

Nurse ___________________________ times per week

Physical Therapist ___________________________ times per week

Occupational Therapist________________________times per week

Speech Therapist ____________________________times per week

Home Health Aide ____________________________times per week

Social worker ____________________________times per week

Treatments to be done by your home health team:

Nurse:__________________________________________________________

Physical Therapist:_________________________________________________

Occupational Therapist:_____________________________________________

Speech Therapist:__________________________________________________

Home Health Aide: ________________________________________________

Social Worker:____________________________________________________

Special instructions you need to know regarding your health or home care:

See attached medication list and instructions.

If you have any questions about your healthcare- we want to know! Please give us a call

Patient Name:

Beneficiary Elected Transfer

Date: Facility:

Address: Tel: RE: Beneficiary Elected Transfer

Patient: HIC#: Effective Date:

To Whom It May Concern:

According to the Regional Home Health Intermediaries (RHHI) inquiry system, patient , HIC no. , has established a plan of home health treatment with your agency. At the request of the beneficiary, services have transferred to our agency (pursuant to section 201.8 of Medicare Home Health Regulations). We wish to inform you of the Beneficiary Elected Transfer (BET). Our agency’s start of care date for services began on the day of .

The beneficiary’s attending physician, has also been informed of the transfer the beneficiary elected to make. Please contact our office should any questions arise regarding this matter.

Sincerely,

Beneficiary Elected Transfer Patient Verification

To Whom It May Concern:

I hereby acknowledge, as of the day of , Lorian Health will be my official provider of home health services rendered to me. No longer should any other agency resume responsibiity or receive compensation for care provided to me.

Patient’s Name (Please print)

Patient’s Signature Date