Admissions Checklist and Consent Form

HOSPICE OF CHARLES COUNTY ADMISSIONCHECKLISTANDCONSENT

PatientName: Pt.#:

 IconsenttoacceptpharmaceuticalservicesprovidedbyHospiceofCharles Countyand to the release of my medical information to obtain medications.  I consent to the medication disposal policy that allows hospice staff to dispose of my medication as outlined in the policy.  I DO NOT consent to the medication disposal policy and accept the responsibility to dispose of the medications in an appropriate manner.

Signature of Patient or Legal Representative Signature of Hospice Representative Date

I acknowledge receipt of the following documents:  HospiceInformation  CoordinationofCare  FinancialPlan  RightsandResponsibilities  GrievanceProcedures  AdvanceDirectiveInformation  HIPAAConsent/AuthorizationNotice  Policy for Home Use and Disposal Controlled Substances and Other Prescribed Medications

I have had the opportunity to review such documents and to ask questions and to discuss their contentswithaHospicerepresentative. IunderstandthescopeofserviceswhichHospiceprovides andmyrightsandresponsibilities. IhaveprovidedtheinformationrequestedunderCoordinationof Care. IhavereviewedtheinformationcontainedintheFinancialPlanandhaveagreedtotheterms of the Plan, including assignment of benefits.

Consent to Release Information: Iauthorize the release of medical and financial informationto or from health care practitioners, medical personnel, government agencies, JCAHO, and insurers, if necessary for the coordination and continuityofmy care, reimbursement forservices andsupplies furnished,orforthequalityofmycare. Suchinformationwillnotbereleasedforanyotherpurpose or to any other person without my written consent or that of my representative.

I consent to admission to Hospice under terms and conditions set forth herein and in the documents attached.

Signature of Patient or Legal Representative

Printed Name of Patient or Legal Representative Date

Date

Signature of Hospice Representative Date

A parent or legal guardian must sign for patients who are under 18 years of age.