1. I understand the goal of hospice is not to cure the terminal illness but to provide symptom relief and supportive care in this final phase of life.

2. I understand the hospice interdisciplinary team will provide education, training, and support in the management of the patient's physical, emotional, psychosocial, and spiritual needs.

3. I understand the hospice staff will provide emotional, psychosocial, and spiritual support to help me cope with my caregiver responsibilities, the eventual patient's death, and my bereavement.

4. I understand that in my role as a primary caregiver, I will be responsible for meeting or arranging for the patient's 24 hours a day care needs. I will arrange for care in my absence.

5. I understand the hospice medical record will contain information about me. Every effort will be made to keep this information confidential. I authorize this information to be released to the attending physician and other appropriate healthcare providers for the patient's care. I also authorize the release of this information, as needed, to process insurance claims.

6. I understand hospice services are primarily provided on a prearranged, appointment basis, but crisis or consultation assistance with hospice is available 24 hours a day, 7 days a week. I will consult hospice in case of any emergency.

7. I understand to receive full benefits of hospice care it is important for me and the patient to make our needs and concerns known to the hospice interdisciplinary team and to participate in the planning for care.

8. I understand I may choose to change my mind about this method of care and withdraw from this primary caregiver agreement. However, I agree not to do so without giving advance notice to the patient and hospice, so another primary caregiver can be arranged for.

9. I have received the Patient/Family Orientation for Hospice Care Packet. At this time, I believe I understand the responsibility of being primary caregiver, the nature of the patient's illness, and the goal of hospice care. My questions about the hospice program have been answered to my satisfaction by the hospice staff.

As a Medicare beneficiary you have the right to appeal the decision of the hospice agency on items not being covered because the hospice has determined they are unrelated to the individual’s terminal illness and related conditions. You have the right to contact the Medicare Beneficiary and Family Centered-Quality Improvement Organization (BFCC-QIO) for immediate assistance. Visit this website to find the BFCC-QIO for your area.

call 1-800-MEIDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

The purpose of this addendum is to notify beneficiary (or representative), in writing, of those conditions, items, services, and drugs the hospice will not be covering because the hospice has determined they are unrelated to the individual’s terminal illness and related conditions. I acknowledge that I have been given a full explanation and have an understanding of the list of items, services and drugs not related to my terminal illness and related conditions not being covered by hospice. Signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not necessarily agreement with the hospice’s determinations.

I acknowledge that I have been provided with information about my financial responsibility for certain hospice services (drug copayment and inpatient respite care). I understand that I have the right to request at any time, in writing, the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum that lists the items, services, and drugs that the hospice has determined to be unrelated to my terminal illness and related conditions that would not be covered by the hospice. I acknowledge that I have been provided information regarding the provision of Immediate Advocacy through the Beneficiary and Family-Centered Care Quality Organization (BFCC-QIO) if I disagree with any of the hospice’s determinations and I have been provided with the contact information for the BFCC-QIO that services my area.

Beneficiary and Family Centered Care Quality Improvement Organization Contact Information

Idaho: Kepro - 888-317-0891

Beneficiary and Family Centered Care Quality Improvement Organizations help file quality of care complaints as well as immediate advocacy services to quickly resolve medical concerns. For information about the availability of auxiliary aids and services please visit:

www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

This website has been designed to comply with Section 508 of the U.S. Rehabilitation Act.

I acknowledge that I have been given a full explanation and have an understanding of the purpose of hospice care.  Hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions and such care will not be directed toward cure. The focus of hospice care is to provide comfort and support to both me and my family/caregivers.

I understand that by electing hospice care under the Medicare Hospice Benefit, I am acknowledging that I understand the palliative rather than curative nature of hospice care, as it relates to my terminal illness and related conditions. I understand that by electing hospice care under the Medicare Hospice Benefit, I am waiving (give up) all rights to Medicare payments for services related to my terminal illness and related conditions and I understand that while this election is in force, Medicare will make payments for care related to my terminal illness and related conditions only to the designated hospice and attending physician that I have selected. I understand that services not related to my terminal illness or related conditions will continue to be eligible for coverage by Medicare; however, I also understand that services unrelated to my terminal illness and related conditions are exceptional and unusual and hospice should cover all care related to my terminal illness and related conditions needed under the hospice election.

It is an honor to care for you, or your loved one during this difficult time. We would like to take a moment to explain the Medicare/Medicaid hospice benefit and what it covers in terms of emergency/ urgent care services.

Once a person chooses to receive hospice care, they enable the hospice benefit election. Part of that benefit is that a patient chooses not to receive curative treatment for their terminal diagnosis. A patient can still call 911 or go to the emergency room for injuries/illnesses that are not related to their terminal diagnosis. However, the hospice agency must be aware of all treatments and services the patient is going to receive prior to receiving care. Hospice can provide most services and treatments, so contact hospice prior to calling 911.

If you or your loved one wish to enable 911 or emergency services, the hospice agency must first obtain a revocation notice from you.

By signing below, you acknowledge that you must sign a revocation notice prior to obtaining any other medical interventions such as emergency services or calling 911. This will enable you to use those services and they will get billed to your insurance instead of you. In the event that you don't sign the revocation form before seeking treatment, the hospital and/or emergency services can bill you for the services instead of your insurance.

Your signature on the affirmations page acknowledges you have received and fully understand All Care Hospice & Palliative Care's explanation of the Medicare/Medicaid Hospice Benefit as it applies to emergency and urgent care services.

• History and Physical Exam
• Progress Notes
• Clinical Summary
• Physician's Notes
• Consultation Reports
• Laboratory Reports
• Operative Reports
• Nurse's Notes
• Pathology Reports
• Outpatient Information
• X-Ray Reports
• Other (Specify):

The patient and/or the patient's authorized agent have full responsibility for the payment of all fees and charges in accordance with All Care Hospice & Palliative Care's fee schedule. It is understood that for hospice patients, All Care Hospice & Palliative Care assumes financial responsibility for medications and/or durable medical equipment and medical supplies related to the terminal illness. The patient and/or patient's agent assumes financial responsibility for all other unauthorized charges. All Care Hospice & Palliative Care, in accordance with this agreement, shall assist the patient in obtaining financial assistance from third-party payers, such as Medicare, Medicaid and private insurers.

Rates: Should a patient choose to receive care from All Care Hospice & Palliative Care without having Medicare, Medicaid, other private insurance, or third party payer source, the following rates will apply:

• Routine Home Care: &166/Day
• Inpatient Care: $704/Day
• Continuous Care: $48/Hour
• Respite Care: $171/Day

If your ability to pay after you are on hospice, you will not be removed from hospice care due to inability to pay.

Medicare/Medicaid hospice care is a Medicare or Medicaid benefit.  As such, patients can choose what hospice agency provides their hospice care.  By signing below, I confirm that I am aware that I have a choice over which agency provides my hospice care and I have chosen All Care Hospice & Pallative Care of my own free will.  If at any time I wish to discontinue care with All Care Hospice & Palliative Care, I or my legal representative must contact All Care Hospice & Palliative Care at (208)473-2717 to cancel. 

I hereby consent for the agency to record or film my care, treatment, and services and allow the agency to use the photographs/recordings for their internal use, for documenting my medical condition, or for insurance providers to document my condition for payment purposes. 

You are receiving the following care at the following daily/weekly/monthly frequencies. If there is a change in any of these services or frequencies, they will be communicated to you:

• Skilled Nursing:  1-2 Times Per Week; 1-2 Additional As Needed
• Aide: 2 Times Per Week
• Social Worker: Evaluation
• Spiritual Care: Evaluation
• Volunteer: Evaluation

All Care Hospice & Palliative Care does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, publication in its programs, services, activities, or in employment. For further information about this policy, contact the All Care Hospice & Palliative Care Administrator at (208) 473-2717.

• Administratior:  Angela Hilleshiem, RN
• Assistant Administrator:  Lance Robinson, RN
• Director of Nursing:  Allison Ashford, RN

Required Services Covered by the Medicare Hospice Benefit

All of the following services are required and covered if they are needed to palliate the symptoms of a terminal diagnosis and are included in the patient's Plan of Care.

• Medicines, medical supplies, and durable medical equipment (hospital bed, walker, etc.)
• Laboratory services
• X-ray and radiation therapy
• Emergency services
• Ambulance and transport services
• Short-term inpatient stays in a hospice facility, hospital, or skilled care facility for management of acute symptoms
• Short-term continuous nursing care in the home for crisis care of acute symptoms that can be managed at home with extra support from the hospice team.
• Five-day inpatient respite periods when caretakers require a break from care giving responsibilities
• Bereavement support and counseling services
• Use of an interdisciplinary team
  • Medical supervision and physician services
  • Individual case management and coordination of care by a registered nurse
  • Intermittent nursing visits
  • Social work services
  • Pastoral counseling and spiritual support provided or coordinated by a hospice chaplain
  • Home health aide and homemaker services
  • Volunteer services
  • Dietary Counseling and physical, occupational, speech, and respiratory therapy services as appropriate

Special Services

I understand that if I need hospitalization or special services not provided by hospice, I or my legal representative must make arrangements for these services. The hospice shall in no way be responsible for failure to provide the same and is hereby released from any liability arising from the fact that I am not provided with such additional care.

I have read and understood the services provided by All Care Hospice & Palliative Care and the four levels of care as outlined above. I have also received a copy of this form.

This is a very serious concern as your personal well-being and safety are of the utmost importance to us. The purpose of this letter is to stress how important it is to follow All Care Hospice & Palliative Care's well-defined safety precautions.

The All Care Hospice & Palliative Care Patient/Family Orientation for Hospice Care binder refers to fire safety and oxygen use precautions. Oxygen greatly enhances combustion and is therefore a primary safety concern while you are on oxygen. Please see Section 6: Safety in the Patient/Family Orientation for Hospice Care binder for further information. Fire Safety/Burn Precautions starts on page 24 and continues through page 25. Specific Oxygen Safety is on page 28.

Your signature on the affirmations page acknowledges you have received and fully understand All Care Hospice & Palliative Care's Oxygen Safety and Fire Precaution Recommendations. Your signature also indicates you will follow the recommendations as set forth in the Patient/Family Orientation Binder for Hospice Care. Failure to do so may lead to serious injury, up to and including death. The patient assumes responsibility for any injury incurred by failure to follow this policy.