Common use of Information received Clause in Contracts

Information received. I have received the following and had the opportunity to have my questions answered regarding: Hospice services and limitations; Eligibility criteria; Hospice Patient Rights and Patient Responsibilities; Advance Directives information and agency policy; Notice of Privacy Rights; Emergency Preparedness Training and planning related to a disruption in service; Pain Management and Symptom, Treatment and Disease Management; Management and disposal of Controlled Substances(Narcotics); Access to My Records; Basic Home and Medication Safety; Infection Control; Hours of operation and On-call availability; Contact information. Client has not made any advance directive and has no Medical Power of Attorney Client has made advance directives, location Client has Medical Power of Attorney, ph # State Client has Do Not Resuscitate order, location I understand that if I make any new or different decisions I will notify Bloom Hospice and I agree to provide a copy of all my Advance Directives and Medical Power of Attorney authorizations. I understand the services an aide can and cannot provide. I participated in the development of the aide care plan. I understand that the aide cannot provide any task that is not on the aide care plan. BH staff have discussed with me and I understand the Statement of Election of Hospice Services. BH staff have made me aware of my right to receive Patient Notification of Hospice Non-Covered Items, Services, and Drugs. I have read and understand both pages of this consent. / Signature Client/Legally Responsible Party Date Printed Name of Legally Responsible Party/ Relation / Signature Bloom Hospice Representative Date Printed Name & Title of Bloom Hospice Rep Patient Name: Hospice Agency Name: Bloom Hospice Hospice Election I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from Bloom Hospice (Name of Hospice Agency) to begin on (Start of Care Date). (Note: The start of care date, also known as the effective date of the election, may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive.) Right to choose an attending physician I understand that I have a right to choose my attending physician to oversee my care. My attending physician will work in collaboration with the hospice agency to provide care related to my terminal illness and related conditions. I do not wish to choose an attending physician. I acknowledge that my choice for an attending physician is: (Please provide any information that will uniquely identify your attending physician choice.) Physician Full name: Hospice Philosophy and Coverage of Hospice Care By electing hospice care under the Medicare hospice benefit, I acknowledge that: I was given an explanation and have a full understanding of the purpose of hospice care including that the nature of hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions and such care will not be directed toward cure. The focus of hospice care is to provide comfort and support to both me and my family/caregivers. I was provided information on which items, services, and drugs the hospice will cover and furnish upon my election to receive hospice care. I was provided with information about potential cost-sharing for certain hospice services, if applicable. I understand that by electing hospice care under the Medicare hospice benefit, I waive (give up) the right to Medicare payments for items, services, and drugs related to my terminal illness and related conditions. This means that while this election is in force, Medicare will make payments for care related to my terminal illness and related conditions only to the designated hospice and attending physician that I have selected. I understand that items, services, and drugs unrelated to my terminal illness and related conditions are exceptional and unusual and, in general, the hospice will be providing virtually all of my care while I am under a hospice election. The items, services, and drugs determined to be unrelated to my terminal illness and related conditions continue to be eligible for coverage by Medicare under separate benefits. Right to Request Notification of Hospice Non-Covered Items, Services, and Drugs As a Medicare beneficiary who elects to receive hospice care, you have the right to request at any time, in writing, the Notification of Hospice Non-Covered Items, Services, and addendum that lists conditions, items, services, and drugs that the hospice has determined to be unrelated to your terminal illness and related conditions, and that will not be covered by the hospice. The hospice must furnish this notification within 5 days, if you request this form on the start of care date, and within 72 hours (or 3 days) if you request this form during the course of hospice care.

Information received. 🞏 I have received the following and had the opportunity to have my questions answered regarding: Hospice services and limitations; Eligibility criteria; Hospice Patient Rights and Patient Responsibilities; Advance Directives information and agency policy; Notice of Privacy Rights; Emergency Preparedness Training and planning related to a disruption in service; Pain Management and Symptom, Treatment and Disease Management; Management and disposal of Controlled Substances(Narcotics); Access to My Records; Basic Home and Medication Safety; Infection Control; Hours of operation and On-call availability; Contact information. ADVANCE DIRECTIVES: 🞏 Client has not made any advance directive and has no Medical Power of Attorney 🞏 Client has made advance directives, location 🞏 Client has Medical Power of Attorney, ph # State 🞏 Client has Do Not Resuscitate order, location I understand that if I make any new or different decisions I will notify Bloom Hospice and I agree to provide a copy of all my Advance Directives and Medical Power of Attorney authorizations. I understand the services an aide can and cannot provide. I participated in the development of the aide care plan. I understand that the aide cannot provide any task that is not on the aide care plan. BH staff have discussed with me and I understand the Statement of Election of Hospice Services. BH staff have made me aware of my right to receive Patient Notification of Hospice Non-Covered Items, Services, and Drugs. CONSENT TO PHOTOGRAPH I have read and understand both pages of this consent. / Signature Client/Legally Responsible Party Date Printed Name of Legally Responsible Party/ Relation / Signature Bloom Hospice Representative Date Printed Name & Title of Bloom Hospice Rep Patient Name: Hospice Agency Name: Bloom Hospice Hospice Election I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from Bloom Hospice (Name of Hospice Agency) to begin on (Start of Care Date). (Note: The start of care date, also known as the effective date of the election, may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive.) Right to choose an attending physician • I understand that I have a right to choose my attending physician to oversee my care. • My attending physician will work in collaboration with the hospice agency to provide care related to my terminal illness and related conditions. □ I do not wish to choose an attending physician. □ I acknowledge that my choice for an attending physician is: (Please provide any information that will uniquely identify your attending physician choice.) Physician Full name: Hospice Philosophy and Coverage of Hospice Care By electing hospice care under the Medicare hospice benefit, I acknowledge that: • I was given an explanation and have a full understanding of the purpose of hospice care including that the nature of hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions and such care will not be directed toward cure. The focus of hospice care is to provide comfort and support to both me and my family/caregivers. • I was provided information on which items, services, and drugs the hospice will cover and furnish upon my election to receive hospice care. • I was provided with information about potential cost-sharing for certain hospice services, if applicable. • I understand that by electing hospice care under the Medicare hospice benefit, I waive (give up) the right to Medicare payments for items, services, and drugs related to my terminal illness and related conditions. This means that while this election is in force, Medicare will make payments for care related to my terminal illness and related conditions only to the designated hospice and attending physician that I have selected. • I understand that items, services, and drugs unrelated to my terminal illness and related conditions are exceptional and unusual and, in general, the hospice will be providing virtually all of my care while I am under a hospice election. The items, services, and drugs determined to be unrelated to my terminal illness and related conditions continue to be eligible for coverage by Medicare under separate benefits. Right to Request “Patient Notification of Hospice Non-Covered Items, Services, and Drugs • As a Medicare beneficiary who elects to receive hospice care, you have the right to request at any time, in writing, the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum that lists conditions, items, services, and drugs that the hospice has determined to be unrelated to your terminal illness and related conditions, and that will not be covered by the hospice. • The hospice must furnish this notification within 5 days, if you request this form on the start of care date, and within 72 hours (or 3 days) if you request this form during the course of hospice care.