CONSENT AND ELECTION AGREEMENT
- The goal of Hospice is to maintain quality of life through the management of pain and other symptoms when no further curative measures are planned.
- I designate ____________________________________ as my primary caregiver. I understand Hospice care is not intended to take the place of my family, care rendered at a facility or my attending physician.
- I designate _____________________________________as my attending physician with whom the Hospice Interdisciplinary Team will consult concerning my care. Physician NPI number___________________________(office to complete).
- I understand, if I need hospitalization or other specialized treatment, I or my legal representative must make arrangements for these services through Joliet Area Community Hospice (JACH).
- I understand that I have the right to formulate Advance Directives, but this is not a requirement to receive hospice services.
- I understand that JACH does not pay for residential room and board in a nursing home or in the Hospice Home.
physician - skilled nursing - aide - medical social services - spiritual counseling - bereavement counseling - volunteers
-dietary counseling - physical, occupational,& speech therapies - lab services (as needed for symptom management)
- medications, medical supplies, and durable medical equipment related to my terminal illness ·levels of care include: general inpatient services, continuous care or respite may be provided when specific criteria is met..
HOSPICE ELECTION MEDICARE/MEDICAID/INSURANCE I understand:
1. If eligible for Medicare or Medicaid hospice benefits, all costs will be paid under these programs and I will have no financial obligation, unless I seek care beyond what is considered medically necessary and is not part of the hospice plan of care. Medicare/Medicaid hospice benefit consists of two consecutive 90 day periods and unlimited 60 day periods.
- If I am electing Medicare/Medicaid Hospice, I waive my rights to regular Medicare/Medicaid benefits for any services related to my terminal illness except for services by my attending if not a JACH employee and treatment for medical conditions unrelated to my terminal illness.
- I understand that I cannot receive hospice care by another hospice agency unless arrangements are made by Joliet Area Community Hospice.
- I have the right to discontinue Hospice services at any time by signing a revocation statement and all previously held Medicare/Medicaid benefits are fully restored immediately upon my signature.
- I may change hospices only once during the benefit period.
- Insurance coverage varies with individual policy. I am responsible for any deductibles, co-payments and costs that exceed policy limits.
- My medical eligibility for hospice services will be evaluated ongoing and, if my prognosis improves, I may be discharged from the hospice program.
AUTHORIZATON FOR PAYMENT
I authorize payment be made on my behalf directly to Joliet Area Community Hospice. My hospice care will be reimbursed through: ___Medicare ___Medicaid ___Insurance other___________________________
Name on card__________________________________#_______________________
Name of Insurance Company ___________________________________Phone #___________________
Claim/Policy #_______________________ Group #_________________
Name of Insured___________________________________
Patient’s relationship to the insured:___________________
DOB of insured:____________________________________
Address of Insurance Company_________________________________________________________________
RELEASE OF INFORMATION
I understand that JACH may need to obtain medical records and related information from hospitals, nursing homes, physicians, pharmacies, home health agencies, insurance companies, health care benefit plans, or others in order to assure continuity of care and proper reimbursement. I hereby consent to and authorize JACH to release information.
My signature on this form acknowledges that I elect to receive hospice services from Joliet Area Community Hospice. I understand hospice care is palliative, rather than curative as it relates to my terminal illness. Services provided by JACH and the coverage provided have been fully explained to me. I have been given the opportunity to discuss the services, requirements, and limitations; my questions regarding the hospice care have been answered to my satisfaction and I have been given a full understanding of hospice care. I have been provided a handbook containing additional information.
I have been given an and understand only those whom I give the code to may communicate with Joliet
Area Community Hospice staff regarding my healthcare.
I elect hospice services effective _____/_____/_____ Time_____________ am / pm
Signature of Patient or Legal Representative__________________________________________Date:_____/_____/_____
Reason Patient Did Not Sign________________________________________________________Date:_____/_____/____