I acknowledge that I have been made aware of my rights and responsibilities as a home health patient/outpatient. I have been given a copy of the Patient Education Book and acknowledge receipt of information regarding my rights as a patient under the Conditions of Participation, the federal Privacy Act rights, the Rights of the Elderly, and other rights as may be applicable, how to file a grievance, and information regarding the Agency's drug testing policy, the policy on abuse, neglect and exploitation, and the Emergency Preparedness Plan. I acknowledge that I have not been solicited or coerced to this agency and realize I can choose any agency to care for my home health needs.

☐ Acknowledged

I acknowledge that I will be receiving the following services:

☐ Certified Home Health   ☐ Outpatient Part B services

I give my permission for authorized personnel of WISDOM HEALTHCARE SERVICES, LLC to perform all necessary procedures and treatments as prescribed by my physician for the delivery of home health care/outpatient services. I understand that an Agency RN will supervise services provided. I understand that I may refuse treatment or terminate services at any time and WISDOM HEALTHCARE SERVICES, LLC may terminate services to me as explained in my Patient Education Booklet.

The proposed Frequency and Duration of services is as follows:

☐ Plan of Care acknowledged

My records are subject to disclosure upon request from the patient or representative and are disclosed to governmental entities under the Privacy Act of 1974. I authorize the release of my records by WISDOM HEALTHCARE SERVICES, LLC for the purpose of review by authorized representatives of Medicare/Medicaid, fiscal intermediaries, state agencies, private insurance companies and other payors for use in determining my home health care benefits. I authorize WISDOM HEALTHCARE SERVICES, LLC to release to or receive from hospitals, physicians, other agencies and other healthcare entities involved in my care all medical records and information pertinent to my care. This consent shall remain effective for a period of time not to exceed two years after my discharge from home health services (with the exception of Medicare audits).

☐ Release of Information acknowledged  •  ☐ HIPAA Notice received

I authorize WISDOM HEALTHCARE SERVICES, LLC to take pictures of me receiving treatment and I authorize release of those photographs to payor sources to document my medical condition to secure payment and for use in advertisement or public education regarding home health services.

☐ I authorize   ☐ I do not authorize

I have read and understand the policy (see Patient Education Booklet) relating to reporting of abuse, neglect or exploitation of clients.

☐ Acknowledged

I understand that the Federal Patient Self-Determination Act of 1990 requires that I be made aware of my right to make healthcare decisions for myself. I understand that I may express my wishes in a document called an Advance Directive (Directive to Physicians / Medical Power of Attorney / Do Not Resuscitate Order [DNR] / Declaration of Mental Health) so that my wishes may be known when I am unable to speak for myself. I agree to provide a copy or to share the contents of any Advance Directives with my home health care providers.

DNR order on file: ☐ Yes ☐ No

☐ Advance Directives explained

WISDOM HEALTHCARE SERVICES, LLC is a 24-hour, 7 days a week nursing service. The nurse/coordinator can be reached by calling 614-316-5493. However, in the case of a serious medical emergency or disaster, please call 911 as this agency is not an emergency service.

Emergency contact: — (—) — —

If you have any concerns, please contact the Administrator or the Supervising Nurse of WISDOM HEALTHCARE SERVICES, LLC at 614-316-5493 to give us the opportunity to resolve your complaint or grievance. Your complaint will be investigated within 10 days of receipt. The entire process from receipt of complaint through resolution will not exceed 30 days.

At any time you may address complaints to the Ohio Department of Health (ODH) at 1-800-342-0553, Monday–Friday 8:00 AM – 5:00 PM, or by email at HCCompliants@odh.ohio.gov. Mail: Ohio Department of Health PCSU, 246 North High Street, Columbus, OH 43215.

In consideration of WISDOM HEALTHCARE SERVICES, LLC furnishing the requested services and/or employee, I agree not to solicit or employ any WISDOM HEALTHCARE SERVICES, LLC employee for a period of six months following the completion of this Contract. In the event I violate the above condition, I shall pay to WISDOM HEALTHCARE SERVICES, LLC, upon demand, the sum of $1,500.00.

I certify that the information given by me in applying for payment under Title XVIII (Medicare) or Title XIX (Medicaid) of the Social Security Act or other federally or state funded programs is true and correct. I request that payment of authorized benefits from Medicare, Medicaid or other responsible payor be made in my behalf and I assign the benefits payable for services to WISDOM HEALTHCARE SERVICES, LLC. Should payment not be made, I will be responsible for services provided to me.

☐ Acknowledged

I authorize direct payment of insurance benefits due to me by my insurance company to WISDOM HEALTHCARE SERVICES, LLC. In the event that my insurance carrier does not accept assignment of benefits, I understand that payments may be sent directly to me and that I am obligated to endorse and directly send such payments to WISDOM HEALTHCARE SERVICES, LLC for payment of my bill.

☐ Acknowledged

The Outcome and Assessment Information Set (OASIS) is a data set collected on all adult Medicare and Medicaid patients receiving skilled home health services. The data is submitted to the Centers for Medicare and Medicaid Services (CMS) and is subject to the Privacy Act of 1974.

☐ I authorize   ☐ I do not authorize the release of OASIS data.

WISDOM HEALTHCARE SERVICES, LLC is committed to delivering HOME CARE to its clients/patients and consumers in a caring and professional manner, in compliance with the program's Conditions of Participation. As a WISDOM HEALTHCARE SERVICES, LLC Client/Patient, you are entitled, minimally, to these rights:

1. To be fully informed, in advance, about your diagnosis, care and treatment in language which you understand.
2. To be provided, at your request, with the agency's policies and procedures as they relate to your care.
3. To be fully informed, in advance, of any changes in care or treatment which may affect your well-being.
4. To refuse any treatment within the confines of the law.
5. To voice complaints or grievances without discrimination or reprisal.
6. To the confidentiality of your medical condition, medical record, social, financial or any other information related to your care.
7. To information as to the identity of other health care providers with which the agency has contractual relationships.
8. To know the case manager(s) responsible for your care and how the case manager / On-Call RN may be contacted.
9. To be assured of respect by the Agency staff to yourself, your significant others, family and friends, as well as your property and personal effects.
10. To be fully informed of financial benefits to WISDOM HEALTHCARE SERVICES, LLC if referred elsewhere, and of items or services furnished for which Medicare or program sponsor may make payment, coverage available, charges not covered, and any changes in charges (within 15 days).
11. To request a fully itemized billing statement.
12. To be fully informed, in advance, of any experimental treatment or participation in research, with your full documented authorization and voluntary consent.
13. To be afforded protection of your rights by your family or guardian in the event that you should be judged legally or medically incompetent.

☐ I have fully understood my rights as explained to me by a staff of WISDOM HEALTHCARE SERVICES, LLC.

This consent is required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to inform you of privacy and confidentiality rights with respect to your health care information.

I. Consent related to the Privacy Statement. I have reviewed the Privacy Practice Statement. I understand the terms may change and I may obtain revised notices by contacting WISDOM HEALTHCARE SERVICES, LLC by phone at 614-316-5493 or in writing at 2575 West Broad St, Suite 6, Columbus, OH 43204.

II. Consent for treatment. With my signature, I authorize WISDOM HEALTHCARE SERVICES, LLC and any employee working under the direction of the organization and its medical staff to provide medical care for me or the patient for whom I am the legal guardian.

III. Verbal / Internet Communication. Answering machine/voicemail message: ☐ Yes ☐ No  •  Message with other residents: ☐ Yes ☐ No  •  Internet: ☐ Yes ☐ No

IV. Release for payment and operations. I authorize WISDOM HEALTHCARE SERVICES, LLC to furnish information to my insurance carrier(s) for payment activities and for operational needs identified in the Privacy Statement.

V. Assignment of benefits. I consent to assign all payments for services I have received from WISDOM HEALTHCARE SERVICES, LLC. I understand I am responsible for co-payments, deductibles, and amounts deemed my responsibility by the payor.

Relationship to patient (if not self): ________________

☐ Privacy Consent acknowledged

I will report to WISDOM HEALTHCARE SERVICES, LLC immediately any hospitalizations, discharges from hospital, falls, emergency room visits, and whenever the squad is called. I will also report to the agency any form of neglect or failure to perform assigned tasks by any staff members of this agency.

☐ Acknowledged

The purpose of this policy is to establish clear guidelines for employees and independent contractors whose services have been engaged by WISDOM HEALTHCARE SERVICES, LLC regarding the provision of transportation to our clients.

As a general rule, no employee or independent contractor shall transport the client, provide transportation for the client, or use their vehicle to transport the client to run errands or other transportation service. Providing the client with transportation while engaged by WISDOM HEALTHCARE SERVICES, LLC, regardless of whose vehicle (employee/contractor or client) is not allowed under any circumstance. If a client requests that our employee/contractor run an errand, transport the client, or provide transportation service on behalf of the client, the employee must politely decline and inform the client that such services are the duties and responsibilities of the client's caregiver, and for reasons of liability/insurance, the agency staff is not permitted to perform such duties.

Client, by his/her signature below, agrees not to request transportation services of Agency staff in order to avoid violation of this policy.

☐ Acknowledged

By signing below, I attest that I have read (or had read to me) each section of this Admission Consent and Contract for Services, that all information provided is true and correct, and that I agree to the terms set forth by WISDOM HEALTHCARE SERVICES, LLC.

☐ Self ☐ Legally authorized representative