Palliative Care

Redefining The Palliative Care Movement

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Visiting Nurse Health System’s Palliative Care Program is redefining the palliative care movement, together with our physician partners, Resurgia Health Solutions’ house-call medical practice, JenCare Senior Medical Center, Dispatch Health, 1st Care Management.

From the comfort and privacy of the place you call home, our distinctive Palliative Care Program carefully evaluates your individual health care needs over time, offering every level of medical care and support. The Palliative Care Program of Visiting Nurse Health System is part of our true in-home health care continuum, offering our patients the complete range of home-based health care services, designed specifically to support our patients in all stages of their health care journey.

Necessary to improving the quality of life while confronting an advanced or life-limiting illness, our Palliative Care Program is a patient-centered, integrated approach to treat, educate, support and comfort each patient, addressing not only the physical symptoms, but the emotional and spiritual challenges as well. By combining both active and compassionate therapies, this program is administered by an integrated team of experienced professionals who support both the patients and their families.

If you or a loved one is in the Atlanta area and need palliative care, call us today, at (404) 869-3000, for more information about our Palliative Care Program.

Palliative Patient Agreement

Patient Name

Home Address

City, State, Zip Code

Date of Birth

Name of Patient's Primary Care Physician (PCP)

Medicare Number

Medicaid Number

Social Security Number

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.

I certify that I have received and read a copy of this Patient Agreement, Patient Rights and Responsibilities, written materials on my right to refuse or accept medical treatment and my right to formulate an advance directive.

I certify I have read each of the documents or that they have been explained to me and that I understand the information.

I also certify that I am the patient or the patient’s legal representative duly authorized to execute the terms of this Patient Agreement.

By clicking "submit," I hereby acknowledge that I have reviewed the Patient Agreement, a hard copy of which has been provided to me, and I hereby consent to and agree to be bound by same.

By signing this document, I hereby acknowledge that I have reviewed the Palliative Care Patient Agreement, a hard copy of which has been provided to me, and I hereby consent to and agree to be bound by the same.

Patient/Legal Representative Signature

Date

Printed Name and Relationship of Legal Representative

Date

Visiting Nurse Health System Representative Signature

Date

Why Refer to Us

We provide Georgia’s largest and oldest complete health and hospice care continuum, delivering top clinical outcomes.

We have among the lowest 60-day hospital readmission rates in Metro Atlanta, according to CMS.
We provide post-acute care, handling the most complex cases.
We provide true Charitable Care, helping Georgia’s most vulnerable patients, often left behind.

We can save you time and energy.

We accept virtually all insurance, and we’ll also accept patients who cannot pay. You won’t have to work with different providers for different patients.
We offer online referral capability and a physician portal, which allows our patients’ physicians to efficiently execute appropriate transitions of care.
With the depth and breadth of our services, we can offer a continuum of care for your patients as their needs change.

We have relationships with Atlanta’s leading hospital systems. View our partners in care for more information.