Sections 1812, 1814, 1815, 1816, 1861, and 1862 of the Social Security Act authorize collection of this information. The primary use of this Information is to process and pay Medicare benefits to or on behalf of eligible individuals. Disclosure of this information may be made to : Peer Review Organizations and Quality Review Organizations in connection with their review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XI of the Social Security Act; State Licensing Boards for review of unethical practices or nonprofessional conduct; A congressional office from the record of an individual in response to an inquiry from the congressional office at the request of that individual.
Where the individual's identification number is his/her Social Security Number (SSN), collection of this information is authorized by Executive Order 9397. Furnishing the information on this form, including the SSN, is voluntary, but failure to do so may result in disapproval of the request for payment of Medicare benefits.
Paper Work Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0357. The time required to complete this information collection is estimated to aver age 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
COVID-19 Liability Release Waiver for Clients
Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), our Agency is taking extra precautions with the care of every client to include health history review and encourage enhanced sanitation/disinfecting procedures in compliance with CDC and Dept. of Health guidance.
Symptoms of COVID-19 may include:
Fever
Fatigue
Dry Cough
Difficulty Breathing
I agree to the following:
I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.
I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30days,
I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30-days,
I understand that CareGiver Pro Homecare cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.
Care Giver Pro Homecare is following these enhanced procedures to prevent the spread ofCOVID-19:
CareGiver Pro Homecare is enhancing protection for clients amid COVID-19 by.
Requiring Clients to immediately report to the Agency any of the symptoms noted above,
Requiring Personal Protective Equipment (PPE) to be worn by both Caregiver and Client when contact is in 6-feet range of each other.
Require both Caregiver and Client follows all the CDC infection control measures, including but not limited to: proper and frequent hand washing and enhanced cleaning of high-contact surfaces,
Wellness Checks for Caregiver: measure and record temperature daily before start of each shift.
Aides with elevated temperature must immediately report this finding to the agency.
Caregiver mandatory use of gloves and face coverings,
Require Caregivers to immediately report to the Agency any of the noted symptoms above.