EREBY REQUEST AND AUTHORIZE EN-CARE INC. (THE “AGENCY”), ITS AGENCIES AND EMPLOYEES TO COME INTO MY HOME TO RENDER SUCH STARTING CARE & OTHER PROFESSIONAL SERVICES AS IS CONSIDERED
THERAPEUTICIALLY NECESSARY AND TO RENDER TREATMENT IN ACCORDANCE WITH THE PRESCRIPTION &
INSTRUCTIONS BUT NOT LIMITED TO THE ADMINISTRATION OF MEDICINES TO
I HERE CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE REQUEST AND AUTHORIZATION FOR CARE AND TREATMENT. I CONSENT TO SUCH NURSING CARE AND OTHER PROFESSIONAL SERVICES AND TREATMENT TO SUCH CHANGES IN CARE ARE CONSIDERED THERAPEUTICALLY NECESSARY AND SO SUCH CHANGES OR TREATMENT AS PHYSICIAN MAY DIRECT. I ALSO CERTIFY THAT NO GUARANTEE OR ASSURANCE HAVE BEEN MADE BY EN-CARE INC.. ITS AGENTS OR EMPLOYEES AS TO THE RESULTS BE OBTAINED.
I AUTHORIZE EN-CARE INC. ITS AGENTS AND EMPLOYEES TO INSPECT AND COPY ALL MEDICAL, HOSPITAL, OR X RAY RECORDS PERTAINING TO ME FOR THE PURPOSE OF RENDERING THE ABOVE DESCRIBE NURSING CARE, OTHER PROFESSIONAL SERVICES AND TREATMENT
I HEREBY AUTHORIZE THE ASSIGNMENT OF PAYMENTS TO EN-CARE INC. OF BENEFITS FOR ALL HOME HEALTH SERVICES AS PRESCRIBED BY THE PHYSICIAN AND AS PROVIDED UNDER THE TERMS OF MY INSURANCE POLICY. I CERTIFY THAT THE FINANCIAL AND INSURANCE INFORMATION SUPPLIED BY ME IS CORRECT. I AUTHORIZE THE RELEASE OF ALL RECORDS REQUIRED TO ACT ON THIS REPORT.
I UNDERSTAND THAT MY HEALTH INSURANCE MAY NOT COVER OR MAY NOT PARTIALLY COVER SERVICES PROVIDED TO ME BY EN-CARE INC. WILL BILL ME FOR ANY BALANCE NOT COVERED BY INSURANCE. I AGREE TO COMPLETE A FINANCIAL INFORMATION FORM TO DETERMINE IF I AM ELIGIBLE FOR CARE AT A REDUCED RATE OR FREE OF CHARGE. IN THE EVENT THAT THE INSURANCE COMPANY PAYS ME DIRECTLY, OR MYESTATE, WILL BE FULLY RESPONSIBLE FOR RESULTING FOR REIMBURSING TO EN-CARE INC.
I HEREBY ACKNOWLEDGE RECEIPT OF THE PATIENTS ADMISSION PACKET INCLUDING:
1.EN-CARE INC BROCHURE
2.PATIENTS BILL OF RIGHTS AND RESPONSIBLITIES
3.ADVANCE DIRECTIVE
4.HEALTH CARE PROXY
5.DISPOSAL OF HOUSEHOLD WASTE SHEET
I ACKNOWLEGE THAT I HAVE RECEIVED COPIES OF THE NEW YORK STATE DEPARTMENT OF HEALTH
PAMPHLETS PLANNING IN ADVANCE FOR YOUR MEDICAL TREATMENT, AND APPOINTING YOUR HEALTH
CARE AGENTS NEW YORK STATE’S PROXY LAW.
