PLEASE SIGN & Return to UAB Home Infusion Therapy Pharmacy
Patient Consent / Authorization & Assignment of Benefits
Patient Name: Date of Birth: Patient ID #:
Consent to Treatment
I hereby request services of UAB Home Infusion Therapy, and I consent to such care, treatment, medications, and procedures as are ordered by my physician and my physician’ s associates to be provided by UAB Home Infusion Therapy.
I understand that UAB Home Infusion Therapy must provide care and services in accordance with a physician’ s instructions. I also understand that if I am in a condition to need hospitalization or special services during the course of my care, which are not provided by UAB Home Infusion Therapy, the services and hospitalization must be arranged by me / my legal representative, or my physician, and are my responsibility.
Medical Release Authorization
I hereby authorize release of all records pertaining to my medical history, treatment, or payment information to an agent of UAB Home Infusion Therapy, which are required for the provision of treatment, payment, or healthcare operations. I also authorize the review of my medical records by any local, state, or federal regulatory agency and accrediting bodies. I understand that verbal communication regarding my care may be discussed via cellular phone which can be considered a non-secure line.
Liability Release and Use of Equipment Notice
NOTE: The following statement may not apply to your therapy, i. e. the use of medical equipment. Please disregard all statements that do not apply to your therapy or plan of treatment.
I understand that there are risks known and unknown associated with the use of all medical equipment, supplies, medications, access devices, and the administration of medication. I further understand that because I am using the medications, devices, equipment and / or supplies at home, immediate emergency medical attention may not be available for all complications, injuries, or adverse results that may occur in connection with their use. I recognize my obligation to return any rented equipment after the termination of my therapy or in the event that the equipment received is no longer necessary and I promise to do so. In addition, I hereby authorize my payer and / or physician to release any personal information to assist in locating the equipment in the event it is not returned. I agree to pay UAB Home Infusion Therapy for the cost of rental equipment if I fail to return it as instructed upon completion of therapy or discontinued use.
Assignment of Insurance Benefits and Release of Information
I hereby authorize my public and / or private insurance company or fund responsible for payment of my care, if applicable, to pay benefits on my behalf directly to UAB Home Infusion Therapy for any products and services, including physician services, furnished to me by UAB Home Infusion Therapy. I also authorize UAB Home Infusion Therapy to request, on my behalf, all public or private insurance benefits for products or services provided to me by UAB Home Infusion Therapy.
I agree to inform UAB Home Infusion Therapy of any change in my status, including but not limited to: change of address, admission to hospital or nursing facility, any change that affects third party payments or my own ability to pay for products and services prescribed by my physician and rendered by UAB Home Infusion Therapy.
Receipt of Admission Information
Prior to admission to homecare, I have received, read or had explained to me, been afforded the opportunity to discuss, and acknowledge the receipt of the following documents and / or information:
• Patient Rights and Responsibilities
• Emergency Preparedness Plan
• Medicare Supplier Standards
• Treatment and Therapy information
• Notice of Privacy Practices
• Ability to participate in my plan of care.
• 24-hour clinical support
• How to file a complaint by calling 1-866-759-3120
• Advance Directive information
• How therapy will be paid for and any financial responsibility
Signature
Patient / Legal Guardian or Responsible Party Relationship Date
Witness
Printed Name
Date
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