Kindly supply your emergency contact information below.
Primary Caregiver
(Individual in charge of providing the patient with day-to-day care. Suitable documentation must be presented.)
Legal Guardian
(Court-appointed individual who makes healthcare decisions on behalf of the patient. The necessary documentation must be presented.)
Health Care Proxy
(The individual appointed by the patient who makes healthcare decisions in their place. Suitable documentation must be presented.)
Answer the insurance questions below.
Insured/Policy Holder's Information
Marketing
By signing this form, I confirm that all the statements I have provided, including my responses to all questions are accurate and honest to the best of my knowledge and belief. I assent to provide the eligibility staff with any information needed to verify statements about my eligibility. I recognize that supplying false information could lead to disqualification and repayment. If my income or the number of individuals in my family should change, I will inform the eligibility staff.
Adult Consent & Acknowledgment For Services
Accomplishment of this consent form is vital to provide services to a patient. While some items may not be applicable to your current situation, we ask that you complete this consent in its entirety in order for us to provide full care during this visit and in future visits. You have the benefit of rescinding this consent by giving written notice at any time.
Consent for Testing and Treatment
By initialing, I hereby grant permission to ICare Team Home Health Care LLC to execute such assessments, treatments, and procedures as required by the medical staff for diagnostic and/or therapeutic purposes, which includes, but is not limited to, STD testing including but not limited to HIV. As a component of the testing and treatment, I may obtain disease-specific prevention, education, and risk-reduction services. State law requires RX Team Home Health Care LLC to disclose my name, address, treatment, and other information to the City of Houston Department of Health & Human Services for known persons who test positive for TB, HIV/AIDS, and syphilis. Individuals who test positive may be contacted by a Disease Intervention Specialist (DIS) to confirm they have been treated successfully and that sex partners who may be vulnerable of acquiring the disease have been notified about their potential risk.
Acknowledgment of Receipt
By initialing, I accept that ICare Team Home Health Care LLC has supplied me with its Notice of Privacy Practices, which elaborates how my health information will be managed in different situations; Client Rights and Responsibilities, which I consent to abide by; Grievance Policy, for registering complaints; and E-Prescribing Information Sheet.
Financial Responsibility
By initialing, I am aware that if I am qualified for services through a grant funded program such as Ryan White or the Department of State Health Services Family Planning (Title X), these resources are payers of last resort. This means that if I currently, or in the future, have Medicare, Medicaid, and/or third party insurance, I may not be entitled to services under these grants. Hence, I agree to promptly report any changes in my financial status and/or insurance coverage to the Eligibility Specialist. If such changes have not been properly reported and if those changes in my status give rise to my disqualification for services under a grant funded program at ICare Team Home Health Care LLC, I recognize that I am wholly responsible for the cost of services provided by ICare Team Home Health Care LLC.
Medicaid/Medicare/Third-Party Insurance
By initialing below, should I become qualified for Medicaid, Medicare, and/or third-party insurance while a client of ICare Team Home Health Care LLC, I permit ICare Team Home Health Care LLC to supply Medicaid and/or Medicare and/or a third-party insurer all of the essential medical information, including my HIV status, to process my claim.
By initialing below, I hereby appoint to ICare Team Home Health Care LLC all payments from Medicaid, Medicare, and/or any other third party insurer for medical services given. I recognize that I am in charge of the cost of services delivered that are not included by my insurance. I also am aware that I may be accountable for my co-pay to be paid before I am examined by a healthcare practitioner.
Consent For Communication with Delegated Individual
By initialing, I permit ICare Team Home Health Care LLC to communicate with the following individual regarding my health care, which may include information about my medical diagnosis, appointments, and eligibility status.
Terms of Consent
By signing below, I consent to the terms and information stated above. I am providing this approval of my own free will. I completely release ICare Team Home Health Care LLC and the Harris County Public Health & Environmental Services, and Ryan White Grant Administration, as well as their Officers, Directors, Board Members, employees, and agents (i.e., volunteers, students) harmless from any and all losses, damages, obligations, liabilities (joint or several), claims, payments, penalties, demands, litigation, suits, defenses, proceedings, judgments, costs, disbursements or expenses (including without fees, disbursements, limitation, and expenses of attorney as well as other professional advisors and of expert witnesses and costs of investigation and preparation) of any kind or nature whatsoever relating to, arising out of, or resulting from my receipt of services. I have had the occasion to raise any questions and have had them addressed in a language that I comprehend. Furthermore, I agree to adhere to the terms of this consent. I am aware that this document stays in effect until I rescind my consent in writing. I also understand that I am able to revoke my consent at any time.
I am aware that providing ICARE Team Home Health Care, LLC with my current and past prescriptions history will help the agency in verifying the safety of my prescriptions and lessening dangerous interactions with the other medications I may be taking.
I hereby consent to give ICARE Team Home Health Care, LLC permission to acquire this medication history electronically from other healthcare organizations, which includes, but is not limited to, pharmacies.
I decline the option of supplying ICARE Team Home Health Care, LLC with my current and past prescriptions history.
By signing below, I accept that I am accomplishing this consent of my own free will to consent as initialed above. I completely release ICARE Team Home Health Care, LLC, their employees, Board Members, and agents (i.e., volunteers and students) harmless from any and all losses, damages, liabilities (joint or several), claims, litigation, payments, proceedings, and suits of any kind or nature whatsoever arising from out of my receipt of this service.
I am aware that this consent shall remain active until I retract my consent in writing at any time.
ICARE Team Home Health Care, LLC partakes in research studies, which include proven or experimental treatments. The ICARE Team Home Health Care, LLC staff would like to examine your records to identify if you are eligible to be a part of current or future studies.
By signing this form, you are only signifying that you are willing to share the information found in your patient records with the ICARE Team Home Health Care, LLC research staff. The lone objective of this information is to identify if you are eligible for a research study. You are not consenting to participate in a research study by signing this form.
This consent may be rescinded at any time, apart from the degree that action may already have been taken in reliance on it.
By submitting this form you agree to the terms of the Privacy Policy.
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