PROFESSIONAL PEDIATRIC HOME CARE
CONSENT FOR TREATMENT
CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
Patient Name: ___________________________________ Birth Date: ____/____/____
MM/ DD / YR
Address: _____________________________________________________________________
_____________________________________________________________________
CONSENT FOR TREATMENT
I hereby consent to the provision of services encompassing examination, routine care, diagnostic
procedures, medical social work, nursing and other therapeutic services by Professional Pediatric
Home Care. I authorize the health professionals to take such actions as are necessary and
desirable in the exercise of professional judgment.
I acknowledge that no guarantees have been made to me as to the extent of examination,
treatments or therapies.
I understand that Professional Pediatric Home Care assumes no responsibility or liability for any
other person, adult or child, in this home except for the one contracted for per this agreement.
CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
1.
Permission to Use and Disclose Your Health Information. By signing this
consent, you authorize us to use and/or disclose your health information for treatment,
community resource planning, payment (including claim appeals processing) or health care
operations. You have the right not to sign this consent. However, if you refuse to sign this
consent, we have the right to refuse to treat you.
2.
Your Rights With Respect to This Consent.
2.1.
Right to Review Notice of Privacy Practices. You have the right to review
a copy of our Notice of Privacy Practices before signing this consent. Our Notice of Privacy
Practices details how we may use and disclose your health information. We may amend the
Notice from time to time. You may obtain a copy of our Notice of Privacy Practices, including
any revisions we have made by contacting the PPHC Compliance Officer at (303) 759-1342.
2.2.
Right to Request Restrictions on Use/Disclosure. You have the right to
request that we restrict how we use and/or disclose your protected health information for the
purpose of providing treatment, obtaining payment for our services, and/or conducting health
care operations. Such requests must be made in writing. Please note that we are not required to
agree to any restriction you may request. If, however, we decide to agree to a restriction you
have requested, we must restrict our use and/or disclosure of your health information in the
manner described in your request. To obtain a restriction request form, please contact the PPHC
Compliance Officer at 8000 E Prentice Ave, B11, Greenwood Village, CO 80111.
PROFESSIONAL PEDIATRIC HOME CARE
CONSENT FOR TREATMENT
CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
2.3.
Right to Revoke Consent. You have the right to revoke this consent at any
time. Your revocation of this consent must be in writing. If you wish to revoke this consent,
please contact the PPHC Compliance Officer, 8000 E Prentice Ave, B11, Greenwood Village,
CO 80111 to obtain a revocation form. Note that your revocation of this consent will not be
effective for disclosures we have already made in reliance on your prior consent. We also have
the right to refuse to provide further treatment if you revoke this consent.
2.4
Right to Receive a Copy of This Consent Form. You have a right to
receive a copy of this consent form after you sign it.
3.
writing.
Effective Period. This consent is effective unless and until you revoke it in
I hereby authorize Professional Pediatric Home Care to provide treatment as stated above
and to use and/or disclose my health information for treatment, payment, or health care
operations.
_____________________________________________________ _____/_____/_____
Patient Signature or Parent/Guardian if patient is under 18
Date
____________________________________________________
If Parent/Guardian, relationship to patient
PLEASE RETURN TO PPHC
PROFESSIONAL PEDIATRIC HOME CARE
PATIENT NAME:______________________________________________
I have received the Client’s Bill of Rights from Professional Pediatric Home
Care. An agency representative has reviewed this with me. I understand the
patient’s rights.
Emergency Contact Information:
In the event of an emergency or unforeseen circumstance, please list all
emergency contacts:
Parent/s or guardian names and all contact phone numbers:
___________________________________________________________
_____________________________________________________________
_____________________________________________________________
Names and phone numbers for any other qualified caregivers:
_____________________________________________________________
_____________________________________________________________
If a non life threatening emergency or an unforeseen circumstance occurs in
which the patient caregiver is not able to care for the patient while a PPHC
provider is present, the PPHC provider will first attempt the emergency
contacts listed above and if no one is available, will then Dial 911. If a life
threatening emergency occurs the provider will first call 911 and then
attempt emergency contacts.
I have reviewed and agree with the above statements.
Signature of Guardian:_______________________________Date:________
Signature of Agency:_______________________________Date:_________
PROFESSIONAL PEDIATRIC HOME CARE
8000 E. Prentice Avenue, B11 Greenwood Village, CO 80111
(303) 759-1342 Fax: (720) 493-4632
Dear Families,
Medicaid requirements necessitate that we know immediately if:
1.
2.
3.
4.
Your child changes doctors.
Your child’s insurance changes in ANY way.
Your Child’s Medicaid status changes.
You receive services from an additional home care agency or
your doctor recommends an additional service. (Medicaid
requires all home care services be provided by one agency
unless the first agency cannot supply a service.)
5. Your child’s health status becomes “acute”. Medicaid defines an
acute episode as one that involves.
 Infections
 New medical conditions such as, but not limited to, stroke,
injury, pressure sores.
 Health concerns requiring hospitalization.
 Return to home after being hospitalized.
 Exacerbation of a chronic condition (such as increasing
seizures).
 New diagnosis of a long-term chronic condition (such as
diabetes).
 Complications of pregnancy.
Please call immediately with any of the above information to (303)
759-1342.
Feel free to call with any questions!
Leave in patient’s home
PROFESSIONAL PEDIATRIC HOME CARE
Patient’s Bill of Rights/Responsibilities
The patient and family have the right to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Be fully informed of all his rights and responsibilities by the home
care agency.
Appropriate, timely and professional care relating to physician
orders without discrimination against race, creed, color, religion,
sex, national origin, sexual preference, or handicap.
Be treated with courtesy and respect by all who provide home health
care services to you.
Participate in the choice of care providers.
Be given proper identification by name and title of everyone who
provides home health care services to you.
Receive information necessary to give informed consent prior to any
procedure or treatment.
Confidentiality of all records, communications, and personal
information.
Review clinical record at their request.
Refuse treatment within the confines of the law and to be informed
of the consequences of his action.
Privacy and protection of his/her property.
Receive a timely response from the agency to his request for service.
Reasonable continuity of care. A patient will be admitted for service
only if the agency has the ability to provide safe professional care at
the level of intensity needed.
Voice grievances and suggest changes in service or staff without
fear or restraint or discrimination.
A fair hearing shall be available to any individual to whom service
has been denied, reduced or terminated or who is otherwise
aggrieved by agency action. The fair hearing procedure is set forth
as appropriate to the patient’s situation (e.g. funding source, level of
care, diagnosis).
Be fully informed of agency policies and charges for services,
including eligibility for third party reimbursement. A patient denied
service solely on his inability to pay has the right to be referred
elsewhere.
16. Honest, accurate and forthright information regarding the home care
industry in general and his chosen agency in particular.
17. Be given information regarding anticipated transfer of home health
care to another health care facility and/or termination of home health
care services.
18. Be informed and participate in planning care and treatment in
advance. The patient/family will be informed of treatment
frequency and duration proposed and any changes in plan of care in
advance.
19. A toll-free Home Health Hotline is available in this state to receive
complaints or questions about local home health agencies. The
hotline number is 1-800-842-8826. Currently this is recording. The
caller is asked to leave their name and number. Someone will
respond during the working hours of 8 a.m. to 5 p.m.
Responsibilities of the home care recipient and family are:
1. Give accurate and complete health information concerning past
illnesses, hospitalization, medications, allergies and other pertinent
items.
2. Assist in developing and maintaining a safe environment.
3. Inform our program when you will not be able to keep a scheduled
visit or shift, or there is a change in your child’s condition.
4. Participate in the development and update of the home health care
plan and teaching plan.
5. Adhere to the home health care plan and/or family contract.
6. Request further information concerning anything that is not
understood.
7. Give information regarding concerns and problems you have to a
home care staff member.
I have read Professional Pediatric Home Care Patient Bill of
Rights/Responsibilities, and understand my rights/responsibilities as a client
receiving home care services from Professional Pediatric Home Care. This
information was presented to me prior to, or at the time of the initial
evaluation.
_____________________________________________________________
Signature of Guardian
Relationship to Patient
Date