CNS Injections - One-time Injection Visit
Initial Consultation Form
Client Consent Agreement - Terms of Service
(for online form submission)
By clicking the SUBMIT button, I agree to the following terms of service.
Consent to Receive Services
I hereby authorize Childress Nursing Services, LLC to render appropriate nursing services, testing, care and treatments to the client named on the CNS Injections - One-time Injection Visit - Initial Consultation Form. I recognize and agree that I have the right to refuse treatment or terminate services by notifying the Childress Nursing Services office. In addition, Childress Nursing Services may terminate service by notifying me of termination and the reason.
Authorization for Emergency Medical Services
At any time while receiving services from Childress Nursing Services, and in the event of any medical emergency, I authorize Childress Nursing Services to provide or obtain such medical treatment as it deems advisable under the circumstances, and I agree to assume sole responsibility for all charges for such treatment.
Release of Medical Records
I hereby consent and request that copies, if necessary, of my prior medical records be delivered to Childress Nursing Services to establish or continue my care plan.
I hereby authorize Childress Nursing Services to release copies of my medical records or reports or such portions or summaries thereof as may be relevant, as permitted by HIPAA and as subject to HIPAA’s minimum necessary standards, to other health care providers or regulatory or accrediting bodies for the purpose of continuing and coordinating my care plan and for quality assurance, survey and accreditation purposes.
I acknowledge that I can revoke this authorization over time as permitted by HIPAA.
Vehicle Release
I agree to notify Childress Nursing Services, in advance, and I understand that I must receive written authorization from the Childress Nursing Services office, before any Childress Nursing Services employee/contractor may operate my automobile or transport me in a Childress Nursing Services employee’s/contractor’s automobile.
I understand and agree that it is my responsibility to maintain automobile liability insurance at the minimum level established by the state covering my automobile and authorized drivers, including Childress Nursing Services employees/contractors, should I permit Childress Nursing Services employee/contractor to operate my automobile. I understand and agree that Childress Nursing Services does not provide insurance coverage under any circumstances for any damages to my automobile, bodily injury or damage to property resulting from the use of my automobile by Childress Nursing Services employees/contractors.
I hereby release Childress Nursing Services and its employees/contractors assigned to me, and hold Childress Nursing Services and such employees/contractors harmless and indemnify them from any claim, liability, or cause of action for any injury to my person (including death), bodily injury to a third party, or property damage resulting from the use of an automobile (whether or not owned by me) if operated by Childress Nursing Services employee/contractor, whether or not prior authorization from the Childress Nursing Services office has been obtained.
Statement of Client Bill of Rights
Each Childress Nursing Services (CNS) client has the right to:
1. Receive effective treatment and quality services from CNS for services identified in the plan of care;
2. Be cared for by appropriately trained or credentialed personnel, contractors and volunteers with coordination of
services;
3. Ongoing participation in the development of the plan of care;
4. Access to the Department of Health's listing of licensed home health agencies and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations;
5. A listing of the total services offered by CNS and those being provided to the patient;
6. Refuse specific treatments or services;
7. The name of the individual within CNS responsible for supervising the patient's care and the manner in which that individual may be contacted;
8. Be treated with courtesy, respect, and privacy;
9. Be free from verbal, mental, sexual, and physical abuse, neglect, exploitation, and discrimination;
10. Have property treated with respect;
11. Privacy and confidentiality of personal information and health care related records;
12. Be informed of what CNS charges for services, to what extent payment may be expected from health insurance, public programs, or other sources, and what charges the patient may be responsible for paying;
13. A fully itemized billing statement upon request, including the date of each service and the charge. Agencies providing services through a managed care plan are not required to provide itemized billing statements;
14. Be informed about advanced directives and Physician-Ordered Life Sustaining Treatments (POLST) and the CNS' scope of responsibility;
15. Be informed of CNS policies and procedures regarding the circumstances that may cause CNS to discharge a patient;
16. Be informed of the CNS' policies and procedures for providing back-up care when services cannot be provided as scheduled;
17. A description of the CNS’ process for patients and family to submit complaints to CNS about the services and care they are receiving and to have those complaints addressed without retaliation;
18. Be informed of the Department of Health’s complaint hotline number, (360) 236-4700, to report complaints about the licensed agency or credentialed health care professionals; and
19. Be informed of the Department of Social and Health Services end harm hotline number, 1-866-363-4276, to report suspected abuse of children or vulnerable adults.
20. The home health agency must ensure that the patient rights under this section are implemented and updated as appropriate.
I certify that I have read and understand the abovementioned Childress Nursing Services’ Client Bill of Rights.
Freedom of Choice
I understand that I have the right to choose any provider of personal care services. I voluntarily select Childress Nursing Services as my provider of services.
Client Rights on Advance Directives
If I have executed an Advance Directive, such as a copy of Living Will and Durable Power of Attorney/Health Care Proxy, and authorize CNS to obtain a copy, then I will email a copy of these documents to Childress Nursing Services at Contact@ChildressNursing.com with subject heading “Advance Directive + Client’s name". I will also maintain a physical copy of the documents at my service address and will indicate to CNS where documents are kept in residence.
Assistance with Medications
I have been informed by Childress Nursing Services that I may be receiving assistance with administration or self-administration of medication from a licensed nurse. If I am requesting services involving the use of home health aides / Certified Nursing Assistants (CNA), I may be receiving assistance with self-administration of medication from an unlicensed person (excluding injections).
I hereby release Childress Nursing Services and employees/contractors from any negative, harmful side effects caused by my body’s intake of the administered medication(s).
Covid-19 pandemic
Until Childress Nursing Services can access broad, point-of-care Covid-19 testing for its clients, I understand that I will be required to answer the Covid-19 questionnaire in my Initial Consultation Form. If CNS determines that I show signs or symptoms of an active Covid-19 infection, then CNS will promptly notify me that I will not be able to receive home services at that time. Also, I understand that my CNS nurse will be arriving at my residence wearing enhanced PPE (Personal Protective Equipment) to include a mask, face shield, gloves, and gown or other protective clothing cover. My CNS nurse will be checking my temperature at my door before entering. If my temperature is 100.4 F/37.8 C or above, then my CNS nurse can refuse to provide services at that time. If I am refused services, then CNS agrees to refund my fee for service on that date (minus only a $75 service cancellation fee) within 3-7 business days after my transaction has cleared by CNS' bank OR can be credited to a later injection visit per my choosing but subject to CNS office approval.
I am consenting to receive home health services from Childress Nursing Services during the COVID-19 outbreak. I understand there is much to learn about the newly emerged COVID-19 including how it spreads and transmitted.
I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19. I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious. I understand that due to the unknowns of this virus, the number of other clients serviced by CNS and the nature of the home care services provided, that I have an increased risk of contracting the virus by receiving home services. I understand that the CDC guidelines do not recommend proceeding with any medical treatment that is non-essential at this time. I confirm that my home injection service is essential at this time.
I understand that the symptoms listed below are representative of COVID-19:
● Fever
● Dry Cough
● Shortness of Breath
● Temperature
● Persistent pain or pressure in the chest
● Bluish lips or face
● Muscle pain
● Sore throat
● New loss of taste or smell
I confirm that I do not display or currently have any of the symptoms that are representative of COVID-19, which are outlined above.
Overtime/Holidays
Unless previously agreed upon, all charges for hourly rate services rendered in excess of forty (40) hours during any work week and/or on holidays will be one and one-half times the applicable rate. Holiday rates on services billed on a per visit basis will be one-half times the applicable rate.
Holiday rates applicable for: New Year’s Eve, New Year’s Day, Easter, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day, Christmas Eve, and Christmas Day.
Service Cancellation Fees
I agree to pay Childress Nursing Services a minimum of four (4) hours of service charges at a rate of $75/hour ($300) on behalf of any care professional employed or contracted by Childress Nursing Services who reports for duty at my service address should I decide to terminate this Agreement without proper notice.
I also agree to pay Childress Nursing Services a $150 administration fee in the event that I book services and later cancel at any time for any reason, except when CNS cancels my services due to suspected active Covid-19 infection. I agree to pay a $75 administration fee, if CNS cancels my services due to a suspected active Covid-19 infection.
Service Interruption
I understand Childress Nursing Services uses its best efforts to provide uninterrupted services; however, sometimes interruptions are unavoidable. During any interruption of service, I understand that I may be responsible for and agree to provide or arrange for backup care. However, Childress Nursing Services will make all reasonable attempts to provide service through their caregivers or another agency.
Termination of Services
I understand that I may terminate this Agreement by giving at least forty-eight (48) hours notice prior to start date of service to Childress Nursing Services. However, I will still be responsible for paying the abovementioned applicable administration fees to Childress Nursing Services.
I understand that Childress Nursing Services may terminate this Agreement by providing at least forty-eight (48) hours notice prior to date of service or other minimum notice required under applicable state law. I recognize that notification may be furnished by telephone, and that written confirmation will follow by mail or e-mail. In those circumstances in which the life, safety, or well-being of care professionals employed or contracted by Childress Nursing Services is or may be jeopardized, failure to pay for services rendered, and/or significant non-compliance with my plan of care, Childress Nursing Services may terminate this Agreement without prior notice.
Termination of Services due to a suspected case of an active Covid-19 infection can be implemented immediately, and I will be notified immediately of service termination by CNS.
PAYMENT PLAN
(for the following service, as indicated on my CNS Injections - One-time Injection Visit - Initial Consultation Form)
In response to the recent Covid-19 pandemic, I understand that Childress Nursing Services is implementing additional safety protocols to keep staff and clients safe. As a result, there will be a temporary Covid-19 surcharge of $15/service visit reflected on my invoice, until the Covid-19 pandemic subsides. These safety measures are meant to reduce the risk of unintended transmission from "Silent Spreaders."
□ One-time Injections = $200 per injection visit.
Estimated injection date: as indicated on my CNS Injections - One-time Injection Visit - Initial Consultation Form. Each additional injection during same visit = $50 per injection.
Includes a) Up to two (2) injections per one (1) injection visit. b) Includes injection visit time until 10:00 pm. Additional fee for Injections from 10:01 pm – 1:00 am = $50/injection visit or from 1:01 am – 5:59 am = $75/injection visit. c) Includes Health Check-up on 1st visit only.
□ Medical injections (non-fertility) – for special case management = specific terms and agreements as indicated on my Initial Consultation Form. Estimated medical injection visits to start and end: as indicated on my Initial Consultation Form.
I agree to the service and payment terms as indicated on my CNS Injections - One-time Injection Visit - Initial Consultation Form, along with any additional or special pricing quoted to me in writing by CNS. I authorize and agree to pay the stated and applicable amounts with the simultaneous booking of my services in the form of a credit/debit card, FSA/HSA debit card, personal check via ACH debit, OR other agreed upon terms.
For services provided by Childress Nursing Services, I understand that I am personally financially responsible for payments, if the information provided by me is invalid or payment is not authorized by the credit card company or bank.
All checks should be made payable to: Childress Nursing Services, LLC.
I understand that my invoice will be sent to my invoice billing email address as indicated on my CNS Injections - One-time Injection Visit - Initial Consultation Form, and I will be expected to pay for services electronically.
Unless otherwise prohibited by applicable law, in the event I fail to pay Childress Nursing Services when due, I agree to pay all costs of collection incurred by Childress Nursing Services, including reasonable attorney’s fees, whether or not suit is initiated.
ADDITIONAL TERMS
Hiring of Childress Nursing Services employees
I acknowledge the considerable expense incurred by Childress Nursing Services in advertising, recruiting, evaluating and retaining employees. Accordingly, I agree that during the term of this Agreement and for one (1) year after termination of this Agreement, I will not (without prior written consent of Childress Nursing Services) solicit, employ, or seek to employ any individual who is currently employed by or has been an employee of Childress Nursing Services within the last year. Nor will I induce any such person to leave his or her employment with CNS. If I violate the foregoing provisions, I agree to pay Childress Nursing Services a finder’s fee of Twenty Thousand Dollars ($20,000) for each such employee.
Direct Payment to Childress Nursing Services employees
I agree not to pay the employees directly. Employees are not authorized to accept, have custody or the use of cash, credit cards or other valuables of a client, unless agreed upon by client and Childress Nursing Services office in writing. Monies or gifts used as tips for service are acceptable only. If cash or other items are advanced to employee, I waive any right to offset this amount from the invoice.
I have read and fully understand the content of this Client Consent Agreement and hereby agree to and authorize the foregoing provisions.
As used in this document, the terms “I,” “me” and “my” refer to and include, in addition to the undersigned, that patient/client named above and others for whom the undersigned is responsible or for whom the undersigned has assumed responsibility in engaging Childress Nursing Services, LLC to provide service to the patient/client.
Note: This form must be agreed upon by the Childress Nursing Services’ client unless the client is a minor; incompetent, or physically incapable of agreeing. This form can also be agreed upon by the client's Legal Guardian/Representative.