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Privacy Act Statement

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.

PATIENT AGREEMENT

Client Representatives '>

Relationship '>

Witness '>

i_authorize_the_staff_to_provide_services)?'checked':''?>> I authorize the staff to provide services, as requested by myself/representative and ordered by my physician. Services provided by Caregiver Pro Homecare, Inc. may include nursing, home health aide, personal care aide, social worker, dietician/nutritionist, physical therapist, speech therapist, occupational therapist, audiologist, respiratory therapist, homemaker, and housekeeper

the_services_provided_by_caregiver_pro_homecare)?'checked':''?>> The services provided by Caregiver Pro Homecare, Inc. will have been explained to me and I understand that I may ref use treatment within the confines of the law after being informed of the consequences of my action

i_give_my_consent_and_authorization_for_release)?'checked':''?>> I give my consent and authorization for release of medical information to Caregiver Pro Homecare, Inc. by physician and other health care provider facilities

i_authorize_caregiver_pro_home)?'checked':''?>> I authorize Caregiver Pro Homecare, Inc. and other licensing/regulatory bodies to periodically examine my medical record for the purpose of checking compliance to the applicable rules, regulations, and standards

i_understand_that_it_would_be_prudent)?'checked':''?>> I understand that it would be prudent and in my best interest to establish a Home Health Service Plan of Care in the event of an emergency such as a fire, hurricane, severe snowstorm, or other natural disaster. Therefore, I hereby grant Caregiver Pro Homecare, i nc. permission to reveal to any governmental agency, supplemental provider agency, community volunteer service, or any other providers of services, medical records regarding my nursing care, except where otherwise prohibited by law. I further understand this would be done as necessary, upon request, in order to ensure a safe and effective emergency preparedness plan of care

i_acknowledge_receiving_verbal)?'checked':''?>> I acknowledge receiving verbal and written information concerning my Rights and Responsibilities as a home care client and the NYS Proxy Law/Advance Directives. I n addition the agency has provided a written procedure f or submitting complaints and concerns, and directions regarding contacting the agency after hours, on weekends, and holidays

i_agree_that_i_shall_be_directly_responsible)?'checked':''?>> I agree that I (or my representative) shall be directly responsible for payment for all home care services provided according to this service agreement. I u understand that the invoices are rendered weekly and payable upon receipt. Late payments over 30 days will result in a 1.5% late fee charge per month

i_agree_to_pay_a_sum_of_2500)?'checked':''?>> I agree to pay a sum of $2500.00 in damages to reimburse Caregiver Pro Homecare, Inc. for the cost of recruiting, hiring, and training, if I directly employ an employee of the company that has provided services within six months of services

Advance Directive

Emergency contact

Designate Other

Privacy Act Statement

Paper Work Burden Statement

COVID-19 Liability Release Waiver for Clients

PATIENT AGREEMENT

Lab Company

Lab Frequency

Payer Type

Insurance Information

Medicaid information

Private Insurance

Credit or Debit Card

EFT

Monthly Invoice