AMA Quality Consulting

OMPANY NAME . when roblem with equipment or

OMPANY NAME . if you ed or if your physician your home care prescription.

us effort to properly care for d and to comply with all home health care plan de-

erns regarding pain and pain

Patient Rights And Responsibilities

us effort in showing respect o YOUR COMPANY

ommitments that has been UR COMPANY NAME ..

equences for adverse outt follow proposed care plan ent.

AME is providing you (the priate Medicare regional caritten information for the to contact the Joint Comunresolved compliant or con-

ernment Benefits Adminis238-9650 -994-6610 General Office ector General (OIG)

PANY NAME

YOUR COMPANY NAME.

Florida law requires that your healthcare provider recognize your rights while you are receiving medical care and that you respect the healthcare provider’s right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your healthcare provider . A Summary of your rights and responsibilities follows:

Patient Rights As an individual receiving home care services from YOUR COMPANY NAME ., let it be known and understood that you have the following rights: 1.

To select those who provide you home care services.

2.

To be provided with legitimate identification by any person or persons who enters your residence to provide home care for you.

3.

4.

5.

6.

To receive the appropriate or prescribed service in a professional manner without discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference, psychosocial state, physical or mental handicap, or personal cultural and ethnic preferences.

To be promptly informed if the prescribed care or services are not within the scope, mission, or philosophy of YOUR COMPANY NAME ., and therefore be provided with transfer assistance to an appropriate care or service organization.

To be dealt with and treated with friendliness, courtesy and respect by each and every individual representing YOUR COMPANY NAME . that provides treatment or services for you and to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation.

To have your confidentiality, privacy, safety, security, and property respected at all times.

7.

To assist in the develop health care program tha best as possible, your c

8.

To be provided with ad which you can give yo commencement of serv service, the transfer of care provider, or the te

9.

To express concerns or modifications to your h fear of discrimination o

10. To request and receive information relative to alternative treatments, the physician's legal re disclosure.

11. To receive care and ser your health care plan, p ally, while being fully COMPANY NAME . p charges.

12. To refuse care, within t and receive professiona the ramifications or con result due to such refus

13. To request and receive costs thereof privately

14. To request and receive or review your medical

15. To formulate and have personnel an advance d Will or a Durable Pow Care, or a Do Not Resu

16. To expect that all infor COMPANY NAME . s and shall not be release

ur healthcare provider you are receiving medical e healthcare provider’s ior on the part of papy of the full text of this ovider . A Summary of ies follows:

ghts

me care services from let it be known and undering rights:

provide you home care

legitimate identification by s who enters your resime care for you.

priate or prescribed service ner without discrimination ex, race, religion, ethnic nce, psychosocial state, ndicap, or personal culrences.

med if the prescribed care thin the scope, mission, or COMPANY NAME ., ided with transfer assiste care or service organi-

treated with friendliness, by each and every individUR COMPANY NAME . nt or services for you and l, physical, sexual, and and exploitation.

ntiality, privacy, safety, y respected at all times.

7.

To assist in the development and planning of your health care program that is designed to satisfy, as best as possible, your current needs.

8.

To be provided with adequate information from which you can give your informed consent for the commencement of service, the continuation of service, the transfer of service to another health care provider, or the termination of service.

9.

To express concerns or grievances or recommend modifications to your home care service without fear of discrimination or reprisal.

10. To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments, risks of treatment within the physician's legal responsibilities of medical disclosure.

11. To receive care and services within the scope of your health care plan, promptly and professionally, while being fully informed as to YOUR COMPANY NAME . policies, procedures, and charges.

12. To refuse care, within the boundaries set by law, and receive professional information relative to the ramifications or consequences that will or may result due to such refusal.

13. To request and receive data regarding services or costs thereof privately and with confidentiality.

14. To request and receive the opportunity to examine or review your medical records.

15. To formulate and have honored by all health care personnel an advance directive such as a Living Will or a Durable Power of Attorney for Health Care, or a Do Not Resuscitate order.

16. To expect that all information received by YOUR COMPANY NAME . shall be kept confidential and shall not be released without written consent.

17. To report a problem re services should be dire ager. Our phone numb store hours are Monda 9:00a.m. to 5:00pm an 2:00 pm. If the problem the consumer and YOU Inc., the next step wou agency number listed b certified complaint.

To Register a Complaint again white or c

Agency for Healthcare Consumer Assis 2727 Manna Tallahassee, F 1-888-419-

TOLL FREE NUMBER FO REGISTR To report abuse, neglect or e 1-800-962-

opment and planning of your hat is designed to satisfy, as current needs.

dequate information from our informed consent for the vice, the continuation of f service to another health ermination of service.

or grievances or recommend home care service without or reprisal.

17. To report a problem regarding equipment and services should be directed to our store man ager. Our phone number is 954-555-5555. Our store hours are Monday through Friday, 9:00a.m. to 5:00pm and Saturday, 10:00 a.m. to 2:00 pm. If the problem is not resolved between the consumer and YOUR COMPANY NAME Inc., the next step would be to call the state agency number listed below to register a certified complaint.

e complete and up-to-date o your condition, treatment, , risks of treatment within esponsibilities of medical

To Register a Complaint against Service or Equipment, white or call :

ervices within the scope of promptly and professioninformed as to YOUR policies, procedures, and

Agency for Healthcare Administration Consumer Assistance Unit 2727 Manna Drive Tallahassee, FL 32308 1-888-419-3456

the boundaries set by law, nal information relative to onsequences that will or may usal.

e data regarding services or y and with confidentiality.

e the opportunity to examine al records.

e honored by all health care directive such as a Living wer of Attorney for Health suscitate order.

rmation received by YOUR shall be kept confidential sed without written consent.

TOLL FREE NUMBER FOR CENTRAL ABUSE REGISTRY: To report abuse, neglect or exploitation, please call 1-800-962-2873

Patient Responsibilities You and YOUR COMPANY NAME . are partners in your health care plan. To ensure the finest care possible, you must understand your role in your health care program. As a patient of YOUR COMPANY NAME ., you are responsible for the following:

1. To provide complete and accurate information concerning your present health, medication, allergies, etc., when appropriate to your care/ service.

2. To inform a staff member, as appropriate, of your health history, including past hospitalizations, illnesses, injuries, etc.

3. To involve yourself, as needed and as able, in developing, carrying out, and modifying your home care service plan, such as properly cleaning and storing your equipment and supplies.

4. To review YOUR COMPANY NAME . safety materials and actively participate in maintaining a safe environment in your home.

5. To request additional assistance or information on any phase of your health care plan you do not fully understand.

6. To notify your attending physician when you feel ill, or encounter any unusual physical or mental stress or sensations.

7. To notify YOUR COMPANY NAME . when you will not be home at the time of a scheduled home care visit.

9.

To notify YOUR CO encountering any pr service.

10. To notify YOUR CO

are to be hospitalize modifies or ceases y

11. To make a consciou equipment supplied other aspects of the veloped for you.

12. To report any conce management.

13. To make a consciou

and consideration to NAME . staff.

14. To meet financial co

agreed to with YOU

15. To accept the conse

comes if you do not or course of treatme

YOUR COMPANY NA patient) with the appropr rier information and writ hotline number on how t mission regarding any un cern: A. Palmetto Gover trators 1-866-23 B. JCAHO 1-800C. State Attorney G D. Office of Inspec 1-800- 447-8477

8. To notify YOUR COMPANY NAME . prior to changing your place of residence or your telephone number.

YOUR COMP

ies

NAME . are partners in re the finest care possible, in your health care proCOMPANY NAME ., you ng:

and accurate information ent health, medication, ppropriate to your care/

9.

To notify YOUR COMPANY NAME . when encountering any problem with equipment or service.

10. To notify YOUR COMPANY NAME . if you are to be hospitalized or if your physician modifies or ceases your home care prescription.

11. To make a conscious effort to properly care for equipment supplied and to comply with all other aspects of the home health care plan developed for you.

12. To report any concerns regarding pain and pain management.

mber, as appropriate, of ncluding past hospitalizaes, etc.

13. To make a conscious effort in showing respect

as needed and as able, in out, and modifying your n, such as properly cleanequipment and supplies.

14. To meet financial commitments that has been

OMPANY NAME . safety y participate in maintainnt in your home.

assistance or information health care plan you do

ing physician when you any unusual physical or ations.

MPANY NAME . when at the time of a scheduled

MPANY NAME . prior to of residence or your tele-

Patient An Responsi

and consideration to YOUR COMPANY NAME . staff.

agreed to with YOUR COMPANY NAME ..

15. To accept the consequences for adverse outcomes if you do not follow proposed care plan or course of treatment.

YOUR COMPANY NAME is providing you (the patient) with the appropriate Medicare regional carrier information and written information for the hotline number on how to contact the Joint Commission regarding any unresolved compliant or concern: A. Palmetto Government Benefits Administrators 1-866-238-9650 B. JCAHO 1-800-994-6610 C. State Attorney General Office D. Office of Inspector General (OIG) 1-800- 447-8477

YOUR COMPANY NAME

YOUR COMPA