Admission Service Agreement Form for Home Health

This two-page, three-part form is the consent for care or service. It can be used to document if the patient has:

A Legal or Selected Representative

Liability for Payment

Assignment of Benefits

Consolidated Billing - Supplies (for Medicare Home Health patients only)  

This form also documents the acknowledgement of information given to the patient for:

Advanced Directives

Patient s Rights and Responsibilities

Statement of Patient Privacy Rights and Privacy Act Statement - Health Care Records

Basic Home Safety

Emergency Planning

Infection Control

Agency's Transfer/Discharge Policy

The Admission Service Agreement requires signatures from the patient and/or their legal representative (if any), admitting clinician and the financial guarantor if different from the legal representative. This form works in conjunction with the Welcome to Home Care Services Booklet (Item #3400B).

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