Consent for Care and Treatment

Patient Name


Consent for Care and Treatment

I consent to treatment from National Home Healthcare consistent with a home health plan of care. I have been informed regarding my right to participate in the planning of my care, and have been encouraged to participate in planning my care, as it will be carried by National Home Healthcare. I understand that I will be involved in planning changes, or making decisions in my case or treatment. I understand that this consent is valid from the date of the first visit to me by National Home Healthcare personnel and that I may withdraw my consent at any time by notice to National Home Healthcare, upon which time services would be discontinued. I understand that admission to and continuation of services is subject to National Home Healthcare policies and procedures. I sign this consent willing and voluntarily.

Notice of Services/Charges (*choose at least one)

National Home Healthcare services may be provided by the following: Registered Nurse (RN), Licensed Practical Nurse (LPN), Physical Therapist (PT), Licensed Physical Therapy Assistant (LPTA), Occupational Therapist (OT), Certified Occupational Therapy Assistant (COTA), Speech/Language Pathologist (ST), Medical Social Worker (MSW), and/or Home Health Aid (HHA).

Proposed Frequency and Duration 

Cost Per Visit

Amount/Visit Paid by Insurance

Patient Co-Pay Per Visit

Additional Comments


National Home Healthcare Will Bill (*choose at least one)

I understand that I am responsible to National Home Healthcare for all charges not paid by my insurance company including any copayments, deductibles, coinsurance, lifetime maximums, or charges for non-covered services. I further understand that I must notify National Home Healthcare if I disenroll or become ineligible for coverage under my current plan.

Authorization for Payment

I certify that the information I have reported with regard to my insurance coverage is correct. I hereby authorize National Home Healthcare to release information from my medical records to any insurer or third party payor. I request that payment of authorized benefits from Medicare, Medicaid, or other responsible payor be made on my behalf to National. National performs insurance checks and processes claims based upon its knowledge and understanding of how it expects my claim to be processed. This is as a service provided to me. I understand that I will ultimately be responsible for any remaining balance not covered by commercial insurance. I understand that if I arrange for services/supplies on my own while under a home health Medicare Plan of Care, Medicare will not reimburse me or the supplier and I will be responsible for their costs. I authorize the refund of overpayments of insurance benefits where my insurance coverages are subject to coordination of benefits bill. I authorize my insurance company/ies to furnish National Home Healthcare with any and all information pertaining to my insurance benefits and status of claims submitted by National Home Healthcare. I authorize payment directly to National Home Healthcare for Medicare benefits (as applicable) and other insurance benefits otherwise payable to me. In the event that my insurance carrier does not accept assignment of benefits, or any other payments are sent directly to me, I will hold them in trust for National Home Healthcare for payment of my bill.

Advance Directive Policy

Our policy on Advance Directives: Patients have the right to make decisions concerning their care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives as permitted under state statutory and case law. The Agency will honor each patient’s known advance directives and inform an individual patient if Agency has any limitations in respecting a patient’s advance directives.

Advance Directive: Patient Self Determination 

I understand that I have the right to make healthcare decisions for myself. I understand that the federal Patient Self-Determination Act of 1990 requires that I be made aware of my right to make healthcare decisions for myself. I have been provided written information about the agency’s healthcare policy and understand 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. I have been informed that if I formulate an Advance Directive (Living Will/Durable Power of Attorney for Health Care) it will be followed by NHHC to the extent permitted by law.

I have a living will 

I have a durable Power of Attorney for Health Care

If yes, name of person given medical power of attorney

Relationship to patient

Contact Information

If yes, copy given to agency?

Unanticipated Service Interruption 

I understand that National Home Healthcare uses reasonable efforts to provide uninterrupted services. However, sometimes interruptions are unavailable due to inclement weather or other natural disasters. During interruption of essential services, I agree to provide or arrange for back-up care, or I agree that National Home Healthcare may assist in arranging for transfer to an appropriate emergency facility.

Property Damage

In consideration for the health treatment being provided to me by National Home Healthcare, I hereby release National Home Healthcare Inc. and it‘s affiliates from any damages to my property except that caused solely by the negligence of National Home Healthcare agents and employees acting within the scope of their employment.

Use and Disclosure of Protected Health Information 

I have received the agency’s Notice of Privacy Practices, which describes how my protected health information may be used and disclosed, and how I can get access to this information. In addition, I consent to the release of my protected health information to National Home Healthcare of all or any part of my medical record by any physician, hospital, or other facility of which I have been a patient, as required for purposes of treatment, payment, or operations.

Authorization for Use and Disclosure; Consent to Photograph

National Home Healthcare is committed to providing high-quality healthcare to its patients. As such, the use of clinical photography is limited to the purposes of diagnosis, treatment, and professional education. Photography is a commonly used means of communication among health care providers to monitor progress and healing (or failure to heal). I hereby consent to be photographed while receiving treatment from National Home Healthcare, and hereby authorize the use or disclosure of the photograph or video for purposes of dissemination to physicians, health professionals, and staff members to assist in my care. You can refuse to have photographs or videos taken for any reason other than for your health records. Refusal will not affect your treatment in any way. You may withdraw consent at any time.

Authorization for Use and Disclosure; Assisted Living

If I am a resident in an Assisted Living Facility, I authorize National Home Healthcare to provide pertinent information to the Assisted Living Facility clinical staff in accordance with the requirements of the ALF. This may include weekly progress reports and/or copies of Visit Notes.



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Signature Certificate
Document name: Consent for Care and Treatment
Unique Document ID: b5a6a47e4ccff370b6f462a14fee50dbf53e9610
Timestamp Audit
2016-11-08 08:54:40 ESTConsent for Care and Treatment Uploaded by National Home Healthcare - IP