PATIENT RIGHTS AND RESPONSIBILITIES: I acknowledge receipt of my rights and responsibilities as a patient and I understand them. I acknowledge that I have chosen Visiting Nurse Health System to provide palliative care. No employee of Visiting Nurse Health System has solicited or coerced my decision in selecting Visiting Nurse Health System.
CONSENT FOR TREATMENT: I hereby give my permission for authorized personnel of Visiting Nurse Health System to perform all necessary procedures and treatments required for admission and ongoing care under the Visiting Nurse Palliative Program. I understand that Visiting Nurse Health System will supervise services provided. I may refuse treatment or terminate services at any time, and Visiting Nurse Health System may terminate their services to me as explained in my orientation.
RELEASE OF INFORMATION: I acknowledge receipt of the Notice of Privacy Practices and was given an opportunity to ask questions and voice concerns. I understand that Visiting Nurse Health System may use or disclose protected health information about me to carry out treatment, payment or healthcare operations. Visiting Nurse Health System may release information to or receive information from insurance companies, health plans, Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of my bill for services; any person or entity affiliated with or representing for purposes of administration, billing and quality and risk management; any hospital, nursing home or other healthcare facility to which I may be/have been admitted; any assisted living or personal care facility of which I am a resident; any physician providing my care; family members and other caregivers who are part of my plan of care; licensing and accrediting bodies and other healthcare providers in order to initiate treatment. I further understand and agree that Visiting Nurse Health System may release my information to contractors or consultants working with Visiting Nurse Health System.
CONSENT TO FILM OR RECORD: I hereby consent for Visiting Nurse Health System to record or film my care, treatment and services and allow Visiting Nurse Health System 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.
GRIEVANCES: I understand that I may voice my concerns regarding the care provided either in writing or verbally to the Director of Hospice and Palliative Care at 404-869-3000. I may also contact the Office of Regulatory Services HealthCare Section which regulates hospice and palliative care in the state of Georgia and maintains a hotline: (404) 657-5727. The website for the state office is https://ors.dhr.georgia.gov.
PAYMENT AND LIABILITY: I understand that I am responsible for the payment of co-pays, coinsurance, deductibles, and the total amount if no reimbursement source is identified, or for any reason they fail to pay. I understand that the BILLING OF INSURANCE IS A SERVICE ONLY AND NOT A GUARANTEE OF PAYMENT. I know my responsibility to provide correct/current information about my insurance, and I will be responsible for any charges incurred if the information provided is not accurate or updated.
CONSENT TO OBSERVATIONS: I grant my permission for students in healthcare related programs, supervisory staff, members of the Board of Directors, healthcare consultants, State of Georgia and The Joint Commission surveyors and representatives of any other certification/accreditation/professional bodies to observe Visiting Nurse Health System employees perform my prescribed care and/or review my medical record. I am aware that I may revoke permission for observation verbally or in writing at any time.
NONDISCRIMINATION: Visiting Nurse Health System and I agree that services are provided without regard to race, color, religion, handicap, national origin, gender preference or ability to pay.