HOSPICE OF THE CHESAPEAKE ADMISSION CHECKLIST AND CONSENT Patient Name:
Pt. #:
I consent to accept pharmaceutical services provided by Hospice of the Chesapeake and 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: Hospice Information Coordination of Care Financial Plan Rights and Responsibilities Grievance Procedures Advance Directive Information HIPAA Consent / Authorization Notice 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 contents with a Hospice representative. I understand the scope of services which Hospice provides and my rights and responsibilities. I have provided the information requested under Coordination of Care. I have reviewed the information contained in the Financial Plan and have agreed to the terms of the Plan, including assignment of benefits. Consent to Release Information: I authorize the release of medical and financial information to or from health care practitioners, medical personnel, government agencies, JCAHO, and insurers, if necessary for the coordination and continuity of my care, reimbursement for services and supplies furnished, or for the quality of my care. Such information will not be released for any other purpose 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
Date
Printed Name of Patient or Legal Representative
Date
Signature of Hospice Representative
Date
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A parent or legal guardian must sign for patients who are under 18 years of age. 9.18.18
White/Chart
Yellow/Family
