PHYSICIAN AUTHORIZATION OF PATIENT TO PARTICIPATE IN LORIAN HEALTH WIRELESS HOME MONITORING PROGRAM

Dear Physician,

Lorian Health is offering a new benefit to our home health patients. We have implemented a wireless home monitoring program with the primary goal of decreasing morbidity and mortality as well as preventing hospitalizations among homebound patients by detecting early signs of deterioration and intervening quickly before health status worsens.

We believe your patient , DOB: who was referred to us for home health services would be a good candidate for this program. We are writing to obtain your authorization for this patient to participate in our program, as well as to obtain standing orders that will be used in conjunction with our program. We also request that you send us by fax the patient’s most up-to-date health records, including medication lists, problem lists, relevant diagnostic studies and most recent clinic notes pertaining to the patient’s ongoing health conditions as listed below:

I would like to have access to my patient’s telehealth information. Initial:

Thank you for your cooperation, and we look forward to providing excellent care to your patient!

Sincerely,

Lorian Health Staff

Tel: (877) 567-4265

Fax: (619) 280-8150

Authorization

(physician printed name) authorize my patient: (patient’s name) to participate in Lorian Health’s Wireless Home Monitoring Program, which includes the use of standing orders that I have indicated below on the attached forms.

I,

Signature Date

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:

Date: Facility:

Beneficiary Elected Transfer

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