Admission Service Agreement for Home Health
This two-page, three-part form is the consent for care or service. It can be used to document if the patient has:
•A Legal or Selected Representative
•Liability for Payment
•Assignment of Benefits
•Consolidated Billing - Supplies (for Medicare Home Health patients only)
This form also documents the acknowledgement of information given to the patient for:
•Advanced Directives
•Patient’s Rights and Responsibilities
•Statement of Patient Privacy Rights and Privacy Act Statement - Health Care Records
•Basic Home Safety
•Emergency Planning
•Infection Control
•Agency's Transfer/Discharge Policy
The Admission Service Agreement requires signatures from the patient and/or their legal representative (if any), admitting clinician and the financial guarantor if different from the legal representative. This form works in conjunction with the Welcome to Home Care Services Booklet (Item #3400B).
- Size: 8 1/2 x 11 (detached)
- Paper: 3-part carbonless form; white, pink and canary copies - all parts print the same
- Ink: Black ink
- Punching: 5-holes top and side
- Packaging: 100/pack