Patient Acknowledgements, Consents, Authorizations and Financial Form

Please fill in the form below

Acknowledgement of Information



I the patient / patient representative acknowledge that I have received the following information in writing/can access links via web and had them verbally explained:

Patient Handbook & Orientation including (ENGLISH | SPANISH):
• Infection Control / Prevention
• Fall and Safety Prevention (ENGLISH | SPANISH):
• Complaint Procedure

Advance Directives Information including: (Download Here)
• Health Care Proxy
• Do Not Resuscitate (DNR)
• Living Will

Notice of Privacy Practices (ENGLISH | SPANISH):

Patient Bill of Rights and Responsibilities (ENGLISH | SPANISH):

Emergency Preparedness / Contact Information (ENGLISH | SPANISH):

Emergency Care Plan (ENGLISH | SPANISH):

Fall Risk Reduction Intervention (ENGLISH | SPANISH):

NYSDOH Brochure “Pain Management, A Guide for Patients” (Download Here)

Pain Scale (Download Here)

Calendar Worksheet (ENGLISH | SPANISH):

CDC and NYS about COVID-19 including:
• CDC About Covid ENGLISH | CDC About Covid SPANISH
• NY State About Covid ENGLISH | NY State About Covid SPANISH

A copy of this will be emailed to the responsible party upon submission. Please provide the email address of the responsible party below.
Clear Signature
By signing, I agree that I have complete understanding of the contents listed above.
If patient is acting on their own behalf, please enter Self.


ACS Patient Consents and Authorizations

Request for Admission, Consent to Treatment and Authorization to Release Information

I request admission to ACS Home Care LLC (ACS) and consent to such care and treatment as is ordered by my attending physician. I understand that my care is directed and monitored by my attending physician. ACS is responsible for following my physician's orders for home care, but assumes no responsibility for any act or omission of the physician. I hereby consent to the release of information by any hospital, skilled nursing facility or home health agency in which I have been a patient, and to disclose all or part of my medical records to ACS.
Please initial above to Request Admission, Consent to Treatment and Approve Authorization to Release Information


Medical Patient's Certification and Authorization to Release Information and Payment Request

I authorize release of all records required to act on this request. I request that payment of authorized benefits be made in my behalf to the ACS Home Care LLC.
Please initial above to acknowledge Medical Patient's Certification and Authorization to Release Information and Payment Request
Assignment of Insurance Benefits

I hereby authorize payment directly to ACS Home Care LLC, any insurance benefits payable to me for home health services and/or rented or purchased durable medical equipment. I understand that I am financially responsible to ACS home Care LLC for the charges not paid or payable under my insurance, in accordance with rates and terms of ACS home Care LLC at the time service is rendered.
Please initial above to acknowledge Assignment of Insurance Benefits
Private Insurance and Self Pay

I agree that in consideration of the services to be rendered to me, I hereby individually obligate myself to pay ACS home Care LLC, in accordance with regular rates and terms of ACS home Care LLC. Should the account be referred to an attorney for collection, I shall pay reasonable attorney's fees and collection expenses. All delinquent accounts bear interest at the legal rate of 18% annually.
Please initial above to acknowledge Private Insurance and Self Pay
Data Review Release

I hereby consent to the release of information to any regulatory and/or accrediting bodies (i.e., CHAP, JCAHO) and to the review of patient data by representatives of such regulatory and/or accrediting bodies.
Please initial above to acknowledge Data Review Release


ADVANCE DIRECTIVES

DISCLAIMER FOR DEMENTIA CLIENTS:

ACS Home Care LLC intends to keep all of its marketing material including the information on its web site at www.thecarespecialists.com accurate and up to date as best as possible. The information provided on any public material including the web site is for educational and informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment.

ACS Home Care LLC does not diagnose, treat or cure Alzheimer’s or any other dementia related disease. ACS Home Care LLC provides help to the patients and families affected by Alzheimer’s and other dementia’s based on the current knowledge and care practices. You agree that any use of information or advice you receive from our web site or through our service is at your own risk and that ACS Home Care LLC is not responsible for any damages or losses resulting from your reliance on such information. Your signature represents acceptance of terms and conditions of this Disclaimer.
Clear Signature
By signing, I agree that I have complete understanding of the contents listed above.
If patient is acting on their own behalf, please enter Self.
If patient is acting on their own behalf, please enter "N/A" Not applicable.



Patient Financial Agreement

ACS Home Care Services

SERVICE (Requested/Authorized number of Days Per Week & Hours Per Day. Duration for each service below is long term with no specific end date.)

Skilled Nursing Visits:
Initial evaluation and visits every 3-6 months or as necessary

Home Health Aide (HHA) / Patient Care Assistant (PCA):
Days and Hours will be your choice if you are paying privately or using your private Long-Term Care Insurance. You can change the days and hours as your needs dictate. If you are receiving these service(s) through a MLTC or County Dept of Social Service, they will determine and approve the days and hours you are entitled to. These days and hours can change according to your needs but must be approved through them.
The undersigned agrees to pay for all services provided by ACS Home Care LLC via the billing selection above. The undersigned hereby understands that if their insurance does not pay that the undersigned becomes financially liable and will be billed for all services. The undersigned will be notified if there are any changes to the fee schedule in the Patient handbook.

The undersigned certifies that the financial and insurance information supplied is correct. In the event that the undersigned gets paid directly from the insurance company, the undersigned will be fully responsible for reimbursing ACS Home Care LLC. Bills are due upon receipt. The undersigned may be required to pay for supplies not covered by insurance, as well as, be responsible for co-payment portion of the supplies. Two week security deposit is required if paying by check. Security deposit is 100% refundable at the end of service and after all invoices have been paid in full.

Should the undersigned choose to pay privately or request additional hours other than what there insurance authorizes, the undersigned will be billed one and one half time (1 1/2) regular rate for all Overtime if such requested by client/undersigned. Overtime is considered to be any time over forty (40.0) hours of work in one seven day work week that is rendered by the same individual. The work week starts on Sunday and ends on Saturday. Holidays are billed at one and one-half (1 1/2) times the regular rate. Holiday bill rates begin at midnight on the day of the holiday through midnight the following day.

Holidays are:
• New Years Day
• Memorial Day
• Independence Day
• Labor Day
• Thanksgiving Day
• Christmas Day
Clear Signature
By signing, I agree that I have complete understanding of the contents listed above.

Refusal to sign this form gives ACS Home Care LLC the option to discontinue services immediately.
If patient is acting on their own behalf, please enter Self.
Above, please enter the reason the patient is unable to sign.

If patient is acting on their own behalf, and is able to sign, please enter "N/A' (Not Applicable)



A copy of this document will be emailed to the responsible party upon Submission.