Home Healthcare Intake

Your financial liability will vary based on your insurance plan. A brief explanation of your potential financial liability by type of Insurance:
● Medicare Part A pays 100% of all medically necessary home health services.
● Medicare Part B pays 80% of some medically necessary home health services.
● Medicare Part C (Medicare Advantage Plans) combines Medicare Part A and B and covers all medically necessary services. This is offered through private insurance companies. Depending on your policy, this may include co-insurance, deductibles, out of pocket costs and other charges.
● Private medical insurance and private pay programs will vary by plan and may include co-insurance, deductibles, out of pocket costs and other charges.

I understand based on the Insurance coverage that I have; I am financially responsible for any co-insurance, deductibles, out of pocket costs and other charges.
I agree to pay for the services provided upon receipt of the invoices.

THIS STATEMENT GIVES YOU ADVICE REQUIRED BY LAW (the Privacy Act of 1974).

THIS STATEMENT IS NOT A CONSENT FORM. IT WILL NOT BE USED TO RELEASE OR TO USE YOUR HEALTH CARE INFORMATION.

I. AUTHORITY FOR COLLECTION OF YOUR INFORMATION, INCLUDING YOUR SOCIAL SECURITY NUMBER, AND WHETHER OR NOT YOU ARE REQUIRED TO PROVIDE INFORMATION FOR THIS ASSESSMENT. Sections 1102(a), 1154, 1861(o), 1861(z), 1863, 1864, 1865, 1866, 1871, 1891(b) of the Social Security Act.
Medicare and Medicaid participating home health agencies must do a complete assessment that accurately reflects your current health and includes information that can be used to show your progress toward your health goals. The home health agency must use the “Outcome and Assessment Information Set” (OASIS) when evaluating your health. To do this, the agency must get information from every patient. This information is used by the Centers for Medicare & Medicaid Services (CMS, the federal Medicare & Medicaid agency) to be sure that the home health agency meets quality standards and gives appropriate health care to its patients. You have the right to refuse to provide information for the assessment to the home health agency. If your information is included in an assessment, it is protected under the federal Privacy Act of 1974 and the “Home Health Agency Outcome and Assessment Information Set” (HHA OASIS) System of Records. You have the right to see, copy, review and request correction of your information in the HHA OASIS System of Records.

II. PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED
The information collected will be entered into the Home Health Agency Outcome and Assessment Information Set (HHA OASIS) System No. 09-70-9002. Your health care information in the HHA OASIS system of Records will be used for the following purposes:
• support litigation involving the Centers for Medicare & Medicaid Services, support regulatory, reimbursement, and policy functions performed within the Centers for Medicare & Medicaid Services or by a contractor or consultant.
• study the effectiveness and quality of care provided by those home health agencies.
• survey and certification of Medicare and Medicaid home health agencies.
• provide for development, validation, and refinement of a Medicare prospective payment system.
• enable regulators to provide home health agencies with data for their internal quality improvement activities.
• support research, evaluation, or epidemiological projects related to the prevention of disease or disability, or the restoration or maintenance of health, and for health care payment related projects; and support constituent requests made to a Congressional representative.

III. ROUTINE USES These “routine uses” specify the circumstances when the Centers for Medicare & Medicaid Services may release your information from the HHA OASIS System of Records without your consent. Each prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information.
Disclosures of the information may be to: 1. The federal Department of Justice for litigation involving the Centers for Medicare & Medicaid Services.
2. Contractors or consultants working for the Centers for Medicare & Medicaid Services to assist in the performance of a service related to this system of records and who need to access these records to perform the activity.
3. An agency of the State government for purposes of determining, evaluating, and/or assessing cost, effectiveness, and/or quality of health care services provided in the State; for developing and operating Medicaid reimbursement systems; or for the administration of Federal/State home health agency programs within the State.
4. Another Federal or State agency to contribute to the accuracy of the Centers for Medicare & Medicaid Services’ health insurance operations (payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHAs.
5. Quality Improvement Organizations, to perform Title XI or Title XVIII functions relating to assessing and improving home health agency quality of care.
6. An individual or organization for research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment related projects.
7. A congressional office in response to a constituent inquiry made at the written request of the constituent about who the record is maintained.

IV. EFFECT ON YOU, IF YOU DO NOT PROVIDE INFORMATION
The home health agency needs the information contained in the Outcome and Assessment Information Set in order to give you quality care. It is important that the information be correct. Incorrect information could result in payment errors. Incorrect information also could make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the home health agency to refuse you services.

NOTE: This statement may be included in the admission packet for all new home health agency admissions. Home health agencies may request you or your representative to sign this statement to document that this statement was given to you. Your signature is NOT required.

CONTACT INFORMATION If you want to ask the Centers for Medicare & Medicaid Services to see, review, copy, or correct your personal health information that the Federal agency maintains in its HHA OASIS System of Records:
Call 1-800-MEDICARE (1-800-633-4227) toll free for assistance in contacting the HHA OASIS System Manager. TTY for the hearing and speech impaired: 1-877-486-2048.

• Provide complete and accurate information to the best of your knowledge about your present complaints and past illness(es), hospitalizations, medications, allergies and other matters relating to your health.
• Remain under a doctor’s care while receiving skilled agency services.
• Notify us of perceived risks or unexpected changes in your condition (e.g., hospitalization, changes in the plan of care, symptoms to be reported, pain, homebound status or change of physician).
• Follow the plan of care and instructions. If you do not follow the POC then you accept responsibility for the outcomes; and your physician will be notified.
• Ask questions when you do not understand about your care, treatment and service or other instruction about what you are expected to do. If you have concerns about your care or cannot comply with the plan, let us know.
• Report and discuss pain, pain relief options and your questions, worries and concerns about pain medication with staff or appropriate medical personnel.
• Tell us if your visit schedule needs to be changed due to medical appointment, family emergencies, etc.
• Tell us if your Medicare or other insurance coverage changes or if you decide to enroll in a Medicare or private HMO (Health Maintenance Organization) or hospice.
• Promptly meet your financial obligations and responsibilities agreed upon with the agency.
• Follow the organization’s rules and regulations.
• Tell us if you have an advance directive or if you change your advance directive.
• Tell us of any problems or dissatisfaction with the services provided.
• Provide a safe and cooperative environment for care to be provided (such as keeping pets confined, not smoking, and/or putting weapons away during your care).
• Show respect and consideration for agency staff and equipment.

“THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.”

Our Agency is required by law to maintain the privacy of protected health information and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information. [45 CFR § 164.520] We will use or disclose protected health information in a manner that is consistent with this notice.

The agency maintains a record (paper/electronic file) of the information we receive and collect about you and of the care we provide to you. This record includes physicians’ orders, assessments, medication lists, clinical progress notes and billing information. As required by law, the agency maintains policies and procedures about our work practices, including how we provide and coordinate care provided to our clients. These policies and procedures include how we create, maintain and protect medical records; access to medical records and information about our clients; how we maintain the confidentiality of all information related to our clients; security of the building and electronic files; and how we educated staff on privacy of client information. As our client, information about you must be used and disclosed to other parties for purposes of treatment, payment and health care operations. Examples of information that must be disclosed:
• Treatment: Providing, coordinating or managing health care and related services, consultation between health care providers relating to a client or referral of a client for health care from one provider to another. For example, we meet on a regular basis to discuss how to coordinate care to clients and schedule visits.
• Payment: Billing and collecting for services provided, determining plan eligibility and coverage, utilization review (UR), precertification, medical necessity review. For example, occasionally the insurance company requests a copy of the medical record to be sent to them for review prior to paying the bill.
• Health Care Operations: General agency administrative and business functions, quality assurance/improvement activities; medical review; auditing functions; developing clinical guidelines; determining the competence or qualifications of health care professionals; evaluating agency performance; and credentialing activities; internal auditing and certain fundraising and marketing activities. For example, our agency periodically holds clinical record review meetings where the consulting professional of our record review committee will audit clinical records for meeting professional standards and utilization review.

The following uses and disclosures do not require your consent, and include, but are not limited to, a release of information contained in financial records and/or medical records, including information concerning communicable diseases such as Human Immune Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress and/or any other related information to:
1. Your insurance company, self-funded or third-party health plan, Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services.
2. Any person or entity affiliated with or representing us for purposes of administration, billing and quality and risk management.
3. Any hospital, nursing home or other health care facility to which you may be admitted.
4. Any assisted living or personal care facility of which you are a resident.
5. Any physician providing you care.
6. Licensing and accrediting bodies.
7. Contact you to provide appointment reminders or information about other health activities we provide.
8. Contact you to raise funds for the Agency.
9. Other health care providers to initiate treatment.

We are permitted to use or disclose information about you without consent or authorization in the following circumstances:
1. In emergency treatment situations, if we attempt to obtain consent as soon as practicable after treatment.
2. Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred from the circumstances.
3. Where we are required by law to provide treatment and we are unable to obtain consent.
4. Where the use or disclosure of medical information about you is required by federal, state or local law.
5. To provide information to state or federal public health authorities, as required by law to: prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify persons of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and notify the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence (if you agree or when required or authorized by law).
6. Health care oversight activities such as audits, investigations, inspections and licensure by a government health oversight agency as authorized by law to monitor the health care system, government programs and compliance with civil rights laws.
7. Certain judicial administrative proceedings if you are involved in a lawsuit or a dispute. We may disclose medical information about you in response to a court or administrative order, a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
8. Certain law enforcement purposes such as helping to identify or locate a suspect, fugitive, material witness or missing person, or to comply with a court order or subpoena and other law enforcement purposes.
9. To coroners, medical examiners and funeral directors, in certain circumstances, for example, to identify a deceased person, determine the cause of death or assist in carrying out their duties.
10. For cadaveric organ, eye or tissue donation purposes to communicate to organizations involved in procuring, banking or transplanting organs and tissues (if you are an organ donor).
11. For certain research purposes under very select circumstances. We may use your health information for research. Before we disclose any of your health information for such research purposes, the project will be subject to an extensive approval process. We will usually request written authorization before granting access to your individually identifiable health information.
12. To avert a serious threat to health and safety: To prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public, such as when a person admits to participation in a violent crime or serious harm to a victim or is an escaped convict. Any disclosure, however would only be to someone able to help prevent the threat.
13. For specialized government functions, including military and veterans’ activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institution and custodial situations.
14. For Workers’ Compensation purposes: Workers’ Compensation or similar programs provide benefits for work related injuries or illness.

We are permitted to use or disclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:
1. Use of a directory (in closed name, location, condition described in general terms) of individuals served by our Agency.
2. To a family member, relative friend, or other identified person, the information relevant to such person’s involvement in your care or payment for care to notify family member, relative, friend, or other identified person of the individual’s location, general condition or death.

Other uses and disclosures will be made only with your written authorization. That authorization may be revoked, in writing, at any time, except in limited situations.

YOUR RIGHTS - You have the right, subject to certain conditions, to:
• Request restrictions on uses and disclosures of your protected health information for treatment, payment or health care operations. However, we are not required to agree to any requested restriction. Restrictions to which we agree will be documented. Agreements for further restrictions may, however, be terminated under applicable circumstances (e.g., emergency treatment).
• Confidential communication of protected health information. We will arrange for you to receive protected health information by reasonable alternative means or at alternative locations. Your request must be in writing. We do not require an explanation for the request as a condition of providing communications on a confidential basis and will attempt to honor reasonable requests for confidential communications.
• Inspect and obtain copies of protected health information which is maintained in a designated record set, except for psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or protected health information that is subject to the Clinical Laboratory Improvements Amendments of 1988 [42 USC § 263a and 45CFR 493 § (a)(2)]. If you request a copy of your health information, we will charge a reasonable fee for copying of 25 cents per page copied.

If we deny access to protected health information, you will receive a timely, written denial in plain language that explains the basis for the denial, your review rights and an explanation of how to exercise those rights. If we do not maintain the medical record, we will tell you where to request the protected health information.
• Request to amend protected health information for as long as the protected health information is maintained in the designated record set. A request to amend your record must be in writing and must include a reason to support the requested amendment. We will act on your request within sixty (60) days of receipt of the request. We may extend the time for such action by up to 30 days, if we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request. We may deny the request for amendment if the information contained in the record was not created by us, unless the originator of the information is no longer available to act on the requested amendment; is not part of the designated medical record set; would not be available for inspection under applicable laws and regulations; and the record is accurate and complete. If we deny your request for amendment, you will receive a timely, written denial in plain language that explains the basis for the denial, your rights to submit a statement disagreeing with the denial and an explanation of how to submit that statement.
• Receive an accounting of disclosures of protected health information made by our Agency for up to six (6) years prior to the date on which the accounting is requested for any reason other than for treatment, payment or health operations and other applicable exceptions. The written accounting includes the date of each disclosure, the name/address (if known) of the entity or person who received the protected health information, a brief description of the information disclosed and a brief statement of the purpose of the disclosure or a copy of your written authorization or a written request for disclosure. We will provide the accountings within 60 days of receipt of a written request. However, we may extend the time period for providing the accounting by 30 days if we provide you with a written statement of the reasons for the delay and the date by which you will receive the information. We will provide the first accounting you request during any 12-monthperiod without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

Final modifications to the HIPAA Privacy, Security, and Enforcement Rules mandated by the Health Information technology for Economic and Clinical Health (HITECH) Act, are as follows:
• You have the right to be notified of a data breach.
• You have the right to ask for a copy of your electronic medical record in an electronic form.
• You have the right to opt out of fundraising communications from Mountain Region Home Health, and we cannot sell your health information without your permission.
• Certain uses of your medical data, such as use of patient information in marketing, require prior disclosure and your authorization. Uses and disclosures not described in this notice will be made only with your authorization.
• If you pay in cash in full (out of pocket) for your treatment, you can instruct Mountain Region Home Health not to share information about your treatment with your health plan.

COMPLAINTS - If you believe that your privacy rights have been violated, you may complain to the Agency or to the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing, and should state the specific incident(s) in terms of subject, date, and other relative matters. A complaint to the Secretary must be filed in writing within 180 days of when the act or omission complained of occurred, and must describe the acts or omissions believed to be in violation of applicable requirements. [45 CFR § 160.306]

EFFECTIVE DATE - This notice is effective March 1, 2013. We are required to abide by the terms of the notice currently in effect, but we reserve the right to change these terms as necessary for all protected health information we maintain. If we change the terms of this notice (while you are receiving service), we will promptly revise and distribute a revised notice to you as soon as practicable by mail, email (if you have agreed to electronic notice) or hand delivery.

The Patient’s Right to Decide

Every competent adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment.

When a person becomes unable to make decisions due to a physical or mental change, such as being in a coma or developing dementia (like Alzheimer’s disease), they are considered incapacitated. Only your primary physician can determine if you are incapacitated. To make sure that an incapacitated person’s decisions about health care will still be respected, the Florida legislature enacted legislation pertaining to health care advance directives (Chapter 765, Florida Statutes). The law recognizes the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death. Additionally, the law states that you do not have to be incapacitated to elect a health care surrogate to make your decisions.

By law hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations (HMOs) are required to provide their patients with written information, such as this pamphlet, concerning health care advance directives. The state rules that require this include 58A-2.0232, 59A-3.254, 59A-4.106, 59A-8.0245, and 59A-12.013, Florida Administrative Code.

Questions About Health Care Advance Directives

What is an advance directive?
It is a written or oral statement about how you want medical decisions made should you not be able to make them yourself and/or it can express your wish to make an anatomical donation after death. Some people make advance directives when they are diagnosed with a life-threatening illness. Others put their wishes into writing while they are healthy, often as part of their estate planning.

Three types of advance directives are:
• A Living Will
• A Health Care Surrogate Designation
• An Anatomical Donation

You might choose to complete one, two, or all three of these forms. This pamphlet provides information to help you decide what will best serve your needs.

What is a living will?
It is a written or oral statement of the kind of medical care you want or do not want if you become unable to make your own decisions. It is called a living will because it takes effect while you are still living. You may wish to speak to your health care provider or attorney to be certain you have completed the living will in a way that your wishes will be understood. What is a health care surrogate designation? It is a document naming another person as your representative to make medical decisions for you if you are unable to make them yourself. You can include instructions about any treatment you want or do not want, similar to a living will. You can also designate an alternate surrogate.

Which is best?
Depending on your individual needs you may wish to complete any one or a combination of the three types of advance directives.

What is an anatomical donation?
It is a document that indicates your wish to donate, at death, all or part of your body. This can be an organ and tissue donation to persons in need, or donation of your body for training of health care workers. You can indicate your choice to be an organ donor by designating it on your driver’s license or state identification card (at your nearest driver’s license office), signing a uniform donor form (seen elsewhere in this pamphlet), or expressing your wish in a living will.

Am I required to have an advance directive under Florida law?
No, there is no legal requirement to complete an advance directive. However, if you have not made an advance directive, decisions about your health care or an anatomical donation may be made for you by a court-appointed guardian, your wife or husband, your adult child, your parent, your adult sibling, an adult relative, or a close friend.

The person making decisions for you may or may not be aware of your wishes. When you make an advance directive, and discuss it with the significant people in your life, it will better assure that your wishes will be carried out the way you want.

Must an attorney prepare the advance directive?
No, the procedures are simple and do not require an attorney, though you may choose to consult one. However, an advance directive, whether it is a written document or an oral statement, needs to be witnessed by two individuals. At least one of the witnesses cannot be a spouse or a blood relative.

Where can I find advance directive forms?
Florida law provides a sample of each of the following forms: a living will, a health care surrogate, and an anatomical donation. Elsewhere in this booklet, we have included sample forms as well as resources where you can find more information and other types of advance directive forms.

Can I change my mind after I write an advance directive?
Yes, you may change or cancel an advance directive at any time. Any changes should be written, signed and dated. However, you can also change an advance directive by oral statement; physical destruction of the advance directive; or by writing a new advance directive.

If your driver’s license or state identification card indicates you are an organ donor, but you no longer want this designation, contact the nearest driver’s license office to cancel the donor designation and a new license or card will be issued to you.

What if I have filled out an advance directive in another state and need treatment in Florida?
An advance directive completed in another state, as described in that state's law, can be honored in Florida.

What should I do with my advance directive if I choose to have one?
• If you designate a health care surrogate and an alternate surrogate be sure to ask them if they agree to take this responsibility, discuss how you would like matters handled, and give them a copy of the document.
• Make sure that your health care provider, attorney, and the significant persons in your life know that you have an advance directive and where it is located. You also may want to give them a copy.
• Set up a file where you can keep a copy of your advance directive (and other important paperwork). Some people keep original papers in a bank safety deposit box. If you do, you may want to keep copies at your house or information concerning the location of your safety deposit box.
• Keep a card or note in your purse or wallet that states that you have an advance directive and where it is located.
• If you change your advance directive, make sure your health care provider, attorney and the significant persons in your life have the latest copy.
If you have questions about your advance directive you may want to discuss these with your health care provider, attorney, or the significant persons in your life.

More Information on Health Care Advance Directives
Before making a decision about advance directives you might want to consider additional options and other sources of information, including the following:
• As an alternative to a health care surrogate, or in addition to, you might want to designate a durable power of attorney. Through a written document, you can name another person to act on your behalf. It is similar to a health care surrogate, but the person can be designated to perform a variety of activities (financial, legal, medical, etc.). You can consult an attorney for further information or read Chapter 709, Florida Statutes.

If you choose someone as your durable power of attorney be sure to ask the person if he or she will agree to take this responsibility, discuss how you would like matters handled, and give the person a copy of the document.

• If you are terminally ill (or if you have a loved one who is in a persistent vegetative state) you may want to consider having a pre-hospital Do Not Resuscitate Order (DNRO). A DNRO identifies people who do not wish to be resuscitated from respiratory or cardiac arrest. The pre-hospital DNRO is a specific yellow form available from the Florida Department of Health (DOH). Your attorney, health care provider, or an ambulance service may also have copies available for your use. You, or your legal representative, and your physician sign the DNRO form. More information is available on the DOH website or www.MyFlorida.com (type DNRO in these website search engines) or call (850) 245-4440.

When you are admitted to a hospital the pre-hospital DNRO may be used during your hospital stay or the hospital may have its own form and procedure for documenting a Do Not Resuscitate Order.
• If a person chooses to donate, after death, his or her body for medical training and research the donation will be coordinated by the Anatomical Board of the State of Florida. You, or your survivors, must arrange with a local funeral home, and pay, for a preliminary embalming and transportation of the body to the Anatomical Board located in Gainesville, Florida. After being used for medical education or research, the body will ordinarily be cremated. The cremains will be returned to the loved ones, if requested at the time of donation, or the Anatomical Board will spread the cremains over the Gulf of Mexico. For further information contact the Anatomical Board of the State of Florida at (800) 628-2594 or www.med.ufl.edu/anatbd.

• If you would like to learn more on organ and tissue donation, please visit the Joshua Abbott Organ and Tissue Donor Registry at www.DonateLifeFlorida.org where you can become organ, tissue and eye donors online. If you have further questions about organ and tissue donation you may want to talk to your health care provider.

• Various organizations also make advance directive forms available. One such document is “Five Wishes” that includes a living will and a health care surrogate designation. “Five Wishes” gives you the opportunity to specify if you want tube feeding, assistance with breathing, pain medication, and other details that might bring you comfort such as what kind of music you might like to hear, among other things. You can find out more at:
Aging with Dignity
www.AgingWithDignity.org
(888) 594-7437

Other resources include:
American Association of Retired Persons (AARP)
www.aarp.org
(Type “advance directives” in the website’s search engine.)

Your local hospital, nursing home, hospice, home health agency, and your attorney or health care provider may be able to assist you with forms or further information.

Brochure: End of Life Issues
www.FloridaHealthFinder.gov
(888) 419-3456

As a home health patient, you have the privacy rights listed below.
• You have the right to know why we need to ask you questions. We are required by law to collect health information to make sure:
1) you get quality health care, and
2) payment for Medicare and Medicaid patients is correct.
• You have the right to have your personal health care information kept confidential. You may be asked to tell us information about yourself so that we will know which home health services will be best for you. We keep anything we le.am about you confidential. This means, only those who are legally authorized to know, or who have a medical need to know, will see your personal health information.
• You have the right to refuse to answer questions. We may need your help in collecting your health information. If you choose not to answer, we will fill in the information as best we can. You do not have to answer every question to get services.
• You have the right to look at your personal health information.
• We know how important it is that the information we collect about you is correct. If you think we made a mistake, ask us to correct it.
• If you are not satisfied with our response, you can ask the Centers for Medicare & Medicaid Services, the federal Medicare and Medicaid agency, to correct your information.

For Patients Who Do Not Have Medicare or Medicaid Coverage

• As a home health patient, there are a few things that you need to know about our collection of your personal health care information.
• Federal and State governments oversee home healthcare to be sure that we furnish quality home health care services, and that you, in particular, get quality home health care services.
• We need to ask you questions because we are required by law to collect health information to make sure that you get quality health care services.
• We will make your information anonymous. That way, the Centers for Medicare & Medicaid Services, the federal agency that oversees this home health agency, cannot know that the information is about you.
• We keep anything we learn about you confidential.

This is a Medicare & Medicaid Approved Notice.