Hospice Admission Consents

Hospice Consents and Election of Benefits

All Care Hospice & Palliative Care
Please Select One:*

I am a patient POA or Designated RepresentativeI am an All Care employee with a patient POA or Designated RepresentativeI am an All Care employee with a self signing patient

This Page To Be Completed By All Care Admitting Staff
I agree, as an All Care Employee, that I will follow the policy set forth by All Care Health Solutions regarding Electronic Signatures and will have the Patient or Patient Representative sign and initial all required signature/initial fields*

Yes
I agree, as an All Care Employee, that I will provide a paper copy of the full (blank) admission packet to the Patient or Patient Representative at the time of completing this form. I will also go through the admission packet with the Patient/Representative while completing this form.*

Yes
All Care Staff First Name*
All Care Staff Last Name*
All Care Staff Title (RN, PT, MSW, etc)*
All Care Staff Email Address*
Please Verify Email Address is Correct. Email Notification will be sent. Confirm your email address ends with @myallcare.net
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ALL CARE STAFF SIGNATURE*

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Electronic Signature Consent and Disclosure
By accepting this disclosure, you are consenting: (i) to execute documents with All Care Health Solutions using e-signature; (ii) to exchange documents with All Care Health Solutions electronically. If you do not consent, All Care Health Solutions will provide an alternative method of document execution.
Additionally, by selecting “Accept” you are agreeing:
- That your use of a keypad, mouse, touchscreen, or other electronic device to select an item, button, icon or similar action, or to otherwise provide All Care Health Solutions with your assent during the document transaction (the “e-Signature”) constitutes your signature and acceptance of the content of the documents.
- That your e-Signature is the legal equivalent of your manual signature on the agreement.
- That your e-signature will be witnessed and verified by a member of All Care Health Solutions staff, and as such will require no certification authority or other third-party verification to validate your e-Signature, and the lack of such certification or third-party verification does not affect the enforceability of your e-Signature.
- That you represent that you are authorized to enter into the agreement for the patient, or yourself, if applicable.
- To conduct business with All Care Health Solutions via electronic documents.
- That All Care Health Solutions will provide a non-electronic copy of all records if you decline to consent the usage of electronic signature and records, upon request.
Electronic Signature Consent and Disclosure*

I ACCEPT

Patient Basic Information
Patient First Name*
Patient Last Name*
Patient Middle Name
Patient Date of Birth*

MonthDayYear
Date
Patient Sex*

MaleFemale
Advanced Directives (Page B15)

I have been made aware of my right to make health care decisions for myself. I am also aware that I may express my wishes in a document called an Advance Directive so that my wishes may be known when I am unable to speak for myself. Please complete the following questions:
Has the Patient Signed a Durable Power Of Attorney for Health Care?*

YesNo
Has the Patient Signed a Living Will?*

YesNo
Has the Patient Signed a POST Form? (Idaho Physician Orders For Scope of Treatment)*

YesNo

Patients Power of Attorney/Representative Contact Information
Full Name (POA or Representative)*
Relationship to Patient*
Email Address (POA or Representative)*
Phone Number (POA or Representative*
Please enter a valid phone number.
Address, City, State, Zip (POA or Representative)*
Reason Patient is unable to sign:*
Pre-Filled For Your Convenience
Do you have Power of Attorney Documents you would like to upload here?*

YesNo
File Upload

Click the Browse Files or Drag and Drop Files into Box
Cancelof
Consent for Primary Caregiver
I agree to accept the role of primary caregiver.*

Yes

Read More About Consent for Primary Caregiver (Page B7)
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.

Additional Family/Friend Contacts (Not Required)

Page B16
Please select the number of additional contacts you would like to add (if any)*
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address
Additional Contact First & Last Name
Additional Contact Phone Number
Additional Contact Relationship to Patient
Additional Contact Email Address
Additional Contact Address

Patient Portal Setup

CMS requires that patient care documents are delivered to the patient, or a representative that the patient designates. This can be a family member, Power of Attorney, or a friend. Please enter an email address, or a name and phone number for this person and input it below. This will speed the process of delivering documents such as a signed copy of this admission packet, visit schedule, orders and communication notes.
Patient or Representative Email. If Unknown Please Provide Name and Phone Number*

Hospice Election of Benefits (Pages B1-B3)
Patient Notification of Hospice Non-Covered Items, Services, and Drugs*

I elect to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”I decline to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”
Note: The hospice makes the decision as to whether or not conditions, items, services, and drugs are related for each beneficiary. This addendum should be shared with other health care providers from which you seek item, services, or drugs, unrelated to your terminal illness and related conditions to assist in making treatment decisions.

Hospice must furnish this addendum within 5 days if requested at the time of hospice election and within 72 hours if requested during the course of hospice care.

Right to Immediate Advocacy (Page B3)
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.

Acknowledgement of non-covered items, services, and drugs not related to my terminalillness and related conditions (Page B3)
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.

Hospice Coverage and Right to Request "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" (Page B1)
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.

Hospice Philosophy (Page B1)
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.

Effects of a Medicare Hospice Election (Page B1)
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.

911/Emergency Services Notice to Protect You (Page B5)
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.

Authorizations for Release of Medical Information (Page B4)

This authorization will remain in effect a maximum of six months from the date of signature and may be canceled in writing at any time. I understand that such cancellation may be harmful to proceedings requiring these records. I do not authorize re-release of this information to anyone. A photocopy of this authorization will be treated in the same manner as the original.
Patient/POA/Representative Authorizes Release of Medical Information for the purpose of Coordination of Care.*

YesNo

All medical and drug records including:
- 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):

Right to Choose an Attending Physician (Page B6)
I understand that I have a right to choose my attending physician to oversee my care. My attending physician will work in collaboration with the hospice agency to provide care related to my terminal illness and related conditions.*

I do not wish to choose and attending physicianI acknowledge that my choice for an attending physician is:
Physician: Dr. Jason Ludwig, D.O. NPI: 1144258534

Office Address: 4740 N Penngrove Way #100. Meridian, ID 83646

I acknowledge and understand the above, and authorize Medicare hospice coverage to be provided by All Care Hospice & Pallative Care effective as early as today's date.

Payment Responsibilities and Additional Consents (Page B15)

Payment Responsibility
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.

Agency Choice
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.

Consent to Film/Record
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.

Frequencies
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

Non Discrimination
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

Hospice Services Disclosure Form (Page B12)

Your signature on the affirmations page acknowledges you have received and fully understand All Care Hospice & PalliativeCare's Hospice Services Disclosure Form.
Medicare Hospice Levels of Care*

ROUTINE HOME CARE is provided in a patient's residence or a nursing facility if they reside thereCONTINUOUS CARE is used to provide intensive care for short periods of time to manage a crisis situation. At least 8 hours of direct one on one care must be required during a 24 hour period, and at least half of that care must be provided by a licensed nurseINPATIENT CARE for the control of acute pain or symptoms that cannot be adequately managed in the home, short-term care is provided in a hospital or skilled nursing facilityRESPITE CARE is provided in a hospital or skilled nursing home to allow the patient's primary care giver a rest. Up to 5 days of respite care are allowed at a time.

Read More about Hospice Services...
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.

Oxygen Use Waiver - Page B18
As our patient, we want to make sure that you get the education, tools, and training you need to remain safely in your home. If you use oxygen, the following conditions can put you at risk. Please ask questions or state your concerns should you have any at any time.*

Being a smoker and having oxygen in your homeSmoking while using oxygenOthers around you smoke while you are using oxygenThe presence of candles, fireplace, wood burning stove, oven, and or barbequeN/A

Read More...
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.

Medicare Benefit Recipients ( Page B13)

The patient understands that application for paymentunder Title XVIII of the Social Security Act may be made and that information must beprovided by the patient in order to receive such payment. The patient hereby certifiesthat the information given in applying for payment under Title XVIII of the SocialSecurity Act is correct. The patient hereby requests payment of authorized Medicarebenefits are to be made on the patient's behalf.
1. All Care Hospice & Palliative Care will receive payment for my care, relating to my terminal illness. Medicare will continue to make payment to my attending physician for services if my physician is neither a hospice employee nor receiving payments from All Care Hospice & Palliative Care. If my physician is a hospice employee, All Care Hospice & Palliative Care will bill Medicare for visits to my physician. I understand that I have the right to seek treatment or therapy for any condition unrelated to my terminal illness in the normal manner. Any such care is not reimbursed by All Care Hospice & Palliative Care.*

Yes (Also Inserts Initials)
2. I accept Medicare benefits related to my terminal illness while enrolled in the Medicare Hospice program. I understand that I must have prior approval from hospice before ordering or receiving treatments, supplies, equipment, or any other service related to my terminal illness. I understand that if I fail to get preauthorization from All Care Hospice & Palliative Care for any services, treatments, supplies, equipment, etc., related to my illness, I may be financially responsible for charges incurred.*

Yes (Also Inserts Initials)
3. The Medicare hospice program is divided into benefit periods consisting of two 90-day periods and unlimited 60-day periods. I must use the benefits periods in the above order. I may discontinue hospice care at any time by completing a revocation statement. If I revoke during a benefit period, I lose the remaining days in that benefit period. I have the option of changing to another hospice once per benefit period.*

Yes (Also Inserts Initials)
4. I acknowledge that I have been given a copy of the Patient's Rights and Responsibilities and Notice of Hospice Privacy Practices.*

Yes (Also Inserts Initials)
5. As a Medicare recipient, I understand the above and authorize hospice Medicare services from All Care Hospice & Palliative Care by signing below.*

Yes (Also Inserts Initials)
Certification: The undersigned hereby certifies that he or she has read the foregoing, received a copy thereof, and is the patient or is the duly authorized patient's agent/representative authorized by the patient to execute the above and accept its terms.

Hospice Consents and Election of Benefits

This Page To Be Completed By All Care Admitting Staff

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Electronic Signature Consent and Disclosure

Patient Basic Information

Advanced Directives (Page B15)

Patients Power of Attorney/Representative Contact Information

Consent for Primary Caregiver

Additional Family/Friend Contacts (Not Required)

Patient Portal Setup

Hospice Election of Benefits (Pages B1-B3)

Authorizations for Release of Medical Information (Page B4)

Right to Choose an Attending Physician (Page B6)

Insurance and Billing (Page B11)

Hospice Benefit Questions

MEDICARE SECONDARY PAYER WORKSHEET (Page B14)

PRIMARY PAYER INFORMATION

Payment Responsibilities and Additional Consents (Page B15)

Hospice Services Disclosure Form (Page B12)

Local and Medical Suppliers (Page B17)

Oxygen Use Waiver - Page B18

TB Screening Upon Admission

Medicare Benefit Recipients ( Page B13)

Statement Affirmations (Page B20)

ELECTRONIC SIGNATURE - THE FOLLOWING TO BE COMPLETED BY PATIENT/POA/REPRESENTATIVE ONLY

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