Infant Care Specialist in Mint Hill, North Carolina

CONSENT TO RECEIVE SERVICES: I hereby, authorize _____________________________(Agency)to render appropriate home care services to me. I have been fully informed of the agency’s assessment and evaluation of my home care needs, the risk of receiving the care, and of declining the home care services. I accept the proposed Plan of Care and authorize services to be provided by the agency’s personnel. I believe my services to be: _____________________________________________________

CHARGE FOR SERVICES: Your initial services from the agency will include the following services, initial frequency of visits and charge per visit, if private insurance or private pay. Payor for services: ____________________________________________________________________________________

Services Frequency Of Visits Duration of Services Charge Per Hour/Visit Payor liability Client Responsibility

Nurse

Aide/PCA

Homemaker/Companion/Sitter

Initial Nursing Assessment

Incremental Services (20-minute increments )

.

CLIENT LIABILITY FOR PAYMENT: You have the right to be advised, before care is initiated, of the extent to which payment for services may be expected and the extent to which payment may be required from you, the Client. We are advising you, orally and in writing, about the cost of items and services to be provided.

MEDICAID/MA PLANS/PRIVATE INSURANCE/LONG TERM CARE:

The insurance company is ___________________________. This insurance company covers ______% of the charges. You are responsible for $__________._____ per visit, which is the balance after insur