Patient – Customer Rights Policy

AGREEMENT AND CONSENT

 1.  Terms of Agreement and Medical Consent:  I understand that by signing this agreement, I authorize provisions of products or services to me by Visiting Nurse Association.  I also understand that I am under control of my attending physician and that Visiting Nurse Association is not liable for any act or omission when following the instructions of said physician.

 2.  Medical Information Authorization:  I hereby authorize my hospital/physician to furnish to an agent of Visiting Nurse Association any and all records pertaining to my medical history, services rendered, or treatment.

 3.  Assignment of Insurance Benefits:  I certify that the information given by me in applying for payment under TITLE XVIII of the Social Security Act or under any other benefits is correct.  I authorize the release of all records to act on this request.  I request that payment of authorized benefits be made directly to the Visiting Nurse Association of Southwestern Indiana, Inc. in my behalf.

 4.  Acknowledgement of Financial Responsibility:  While there may be insurance coverage for those services or products provided by Visiting Nurse Association to me relative to my therapy needs, I recognize that all services may not be covered or that reimbursement may be less than 100 percent of charges billed, in accordance with my policy coverage.  Therefore, I acknowledge financial responsibility for any balance owing on  my account.

 5.  Patient Bill of Rights and Responsibilities/Advance Directives:  I have received verbal and written notice of VNA Plus’ Patient/Client Rights and Responsibilities and Advance Directives and have read and understand the contents.

 6.  Returned Goods Policy:  I understand that drugs and supplies dispensed to me may not be returned to Visiting Nurse Association for credit.

 7.  Outpatient Therapy:  I understand that all outpatient therapy services (physical, speech, and occupational therapy) must be coordinated and approved through VNA Plus while I am a patient of VNA Plus and that I must have all outpatient therapy services prior authorized by VNA Plus before I receive any outpatient therapy services.  I understand that VNA Plus is not financially responsible for outpatient therapy services provided by an outpatient provider unless those services were furnished under a contract between the outpatient provider and VNA Plus.

8.  Beneficiary Elected Transfer Verification:  I understand that if I am currently under an established plan of care from another home health or hospice agency that upon admission to VNA Plus the initial home health or hospice agency will no longer receive Medicare payments on my behalf and will no longer provide home care or hospice services to me after the date of admission.

 9.  Facility Directory:  I understand that if I am a patient in the VNA Plus Hospice Center, I am automatically included in the facility directory.  This will allow VNA Plus to provide my room number and general condition if asked for by name and my religious affiliation to clergy without asking by name.  If I do not want to be included in this directory, I will designate that below.  If I opt out of this directory, I understand that if family members, my clergy, neighbors, or friends inquire about me while I am a patient, my presence here will not be disclosed and that mail or flowers addressed to me will be returned.

□    I understand that checking this box signifies that I do NOT want to be a part of the facility directory and my presence here  will be kept confidential to the fullest extent of VNA Plus’ ability to comply with my request.

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Nursing staff may be reached 24 hours a day, 7 days a week by calling the VNA Plus office nearest you:

 Evansville, IN     -   (812) 425-3561

Princeton, IN     -   (812) 385-8857

Tell City, IN       -   (812) 547-7967

Eldorado, IL      -   (618) 273-9305

In case of emergency:  For areas with the 911 emergency service, dial 911.  For areas without 911 emergency service, call the emergency numbers listed in your area telephone directory.

PATIENT/CLIENT RIGHTS AND RESPONSIBILITIES

YOU OR YOUR LEGAL REPRESENTATIVE HAVE THE RIGHT:

1.    To be fully informed of your rights and responsibilities through effective means of communication before receiving any home health or hospice care service and to exercise these rights.  Your family or legal representative may exercise your rights as permitted by law.

2.    To participate in the planning of your home health or hospice care and treatment and to be informed, in advance, of changes in your care including a 5-day discharge notice in accordance with federal and state regulations unless waived by law.  As a participant in your care, you have the right to know what services you are to receive, how often you are to receive them, and that all services, including therapies and supplies, will be provided by VNA Plus.  You also have the right to make decisions about your medical care including the right to accept or refuse care.

3.    To form Advance Directives which direct your care, in accordance with state law.  The administering of care to you will not be affected by whether you have or don’t have Advance Directives in place.

4.    To confidential clinical records concerning your care and treatment as well as access to those clinical records as permitted by law.  A fee for copies of the clinical record will be charged as permitted by law and when applicable.  Requests for access to the clinical record may be made to the Agency’s Health Information Manager.  Disclosure of information will occur only as required by law or when authorized by you or your legal representative.

5.    To have your person and property treated with respect and dignity and to be free from verbal, physical, psychological and sexual abuse, including injuries of unknown source.

6.    To participate in the consideration of ethical issues arising in your care.

7.    To voice grievances about your treatment or care that is (or fails to be) furnished or regarding the lack of respect for property by anyone who is furnishing services on behalf of the Agency without fear of discrimination or reprisal.  You may inform the Agency of such concerns in writing or by telephone by contacting:

VNA Plus – Director of Corporate Services

PO Box 3487

Evansville, IN  47734-3487          PHONE:  1-800-326-4862.

8.    To be informed of the home care or hospice benefits that are available for the items and services that the Agency furnishes (directly or under arrangements with others).  This information shall include coverage available under Medicare and Medicaid and under other public and private, third-party payor programs of which the Agency can be reasonably expected to have knowledge.  You will also be informed of the charges for which you may be liable. You have the right to receive this information orally and in writing, within 30 working days of the date the Agency becomes aware of any changes in charges.  You have the right to have access, upon request, to all bills for service you have received regardless of whether they are paid out-of-pocket or by another party.

9.    To be informed of the availability of the State Home Health Agency Hotline:

IN INDIANA CALL:  1-800-227-6334.  Hours of operation for this hotline are 8 a.m. to 4:45 p.m., Monday-Friday. 

Voice mail is available to take calls after hours, weekends, and holidays.

IN ILLINOIS CALL:  1-800-252-4343.  Hours of operation for this hotline are 8 a.m. to 4:30 p.m., Monday-Friday.

IN KENTUCKY CALL:  1-800-635-6290.  Hours of operation for this hotline are 8 a.m. to 4:30 p.m., Monday-Friday.  An answering machine is available to record messages after hours and on holidays.

10.  To be informed that the State Home Health Agency Hotline may be used to lodge complaints concerning the implementation of the Advance Directives requirement or regarding treatment or care that is (or fails to be) furnished by a home health or hospice agency.

11.  To be informed of the policy governing compliance with Universal Precautions; this information is available upon request.

12.  To request a listing of all individuals or other legal entities who have an ownership or control interest in the Agency.

 PATIENT RESPONSIBILITIES

YOU OR YOUR LEGAL REPRESENTATIVE ARE RESPONSIBLE FOR:

1.    Providing complete and accurate information about illnesses, hospitalization, medications, and other matters relating to your health, including all information on the presence of any other agencies or support services in your home.

2.    Informing the Agency when you will not be able to keep a home health or hospice care visit.

3.    Treating Agency personnel with respect.

4.    Cooperating with Agency personnel and asking questions if you do not understand any instructions or information given you.

5.    Following your home health or hospice care plan.

6.    Participating in the planning of your home health or hospice care treatment.

7.    Providing to the Agency any information necessary for processing third-party payment of charges for the items and services provided by the Agency and/or making arrangements for payment of your bill.

8.    Understanding the following criteria that, when taken singularly or in any combination, indicate an appropriate basis for discharge from VNA Plus services:

a.  The patient establishes residence outside the VNA Plus service area.

b. The services needed by the patient exceed the limitations of VNA Plus policies.

c.  The services needed by the patient exceed the limitations of the availability of VNA Plus staff.

d. The home setting is one in which the services can no longer be rendered effectively in the best interests of the patient and/or the VNA Plus staff.  This includes environment factors which endanger the safety of VNA Plus employee.

e.  The patient and/or patient’s support system is incapable or unwilling to cooperate or participate in the patient’s care.

f.  The patient’s home health or hospice care needs are met.

g.  Agency financial limitations are such that the patient’s services can no longer be funded.

h.  There is lack of physician certification/orders.

CUSTOMER BILL OF RIGHTS

1. To be fully informed of your rights and responsibilities through effective means of communication before receiving any home health care service and to exercise these rights.  Your family or legal representative may exercise your rights as permitted by law.  A written notice of the customer’s rights will be provided before initiation of care.
2. To participate in the planning of your home health care and treatment and to be informed, in advance, of changes in your care including a 5-day discharge notice in accordance with federal and state regulations unless waived by law.  As a participant in your care, you have the right to know what services you are to receive, and how often you are to receive them and the right to make decisions about your medical care including the right to accept or refuse care.To form Advance Directives, which direct your care.  The administering of care to you will not be affected by whether you have or don’t have advance directives in place.
3. To maintain confidential clinical records and for the agency to safeguard your Protected Health Information in accordance with the Health Insurance Portability and Accountability Act unless waived by law.
4. To access your Protected Health Information.  When requesting copies of Protected Health Information, a $0.25 charge per page will be assessed plus postage and handling.  To request access to your Protected Health Information, contact the Privacy Officer at the phone number listed below.
5. To be informed of the agency’s policies on disclosure of medical information and how the agency will use and disclose your Protected Health Information.  Use and disclosure of Protected Health Information is described in the VNP Notice of Privacy Practices.  Disclosure of Protected Health Information not described in the VNA Plus Notice of Privacy Practices shall be authorized by you or your legal representative unless waived by law.
6. To have your property treated with respect and dignity, and to be free from verbal, physical, and psychological abuse.
7. To participate in the consideration of ethical issues arising in your care.
8. To voice grievances without fear of discrimination or reprisal about your treatment or care that is (or fails to be) furnished or regarding the lack of respect for property by anyone who is furnishing services on behalf of the agency.  You may inform the agency of such concerns in writing or by telephone by contacting the Privacy Officer listed below.
9. To know about the disposition of such complaints.  The agency will investigate complaints made by a customer or customer’s legal representative regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for the customer’s property by anyone furnishing services on behalf of the agency.  The agency will document the existence of the complaint and the resolution of the complaint.
10. To be informed of the availability of the state home health agency hot line to lodge complaints concerning the implementation of the Advance Directives requirements or regarding treatment or care that is (or fails to be) furnished by the home health agency.  IN INDIANA CALL: 1-800-227-6334.  This number is available 24 hours/day, 7 days a week for filing complaints or making inquiries.  Voice mail is available after hours and on holidays and weekends.
11. To be informed of the charges for which you may be liable.  You have the right to receive this information orally and in writing, within thirty working days of the date the agency becomes aware of any changes in charges.  You have the right to have access, upon request, to all bills for service you have received regardless of whether they are paid out-of-pocket or by another party.
12. You have the right to be informed of policies governing compliance with Universal Precautions.  This information is available upon request.
13. To request a listing of all individuals or other legal entities who have ownership or control interest in the agency.

CUSTOMER RESPONSIBILITIES

*If applicable to the services you receive:

1. You are responsible for providing complete and accurate information about illnesses, hospitalizations, medications and other matters relating to your health.
2. You are responsible for informing the agency when you will not be able to remain at home for services to be provided.
3. You are responsible for treating agency personnel with respect.
4. You are responsible for cooperating with agency personnel and asking questions if you do not understand any instructions or information given you.
5. You are responsible for following your home health care plan.
6. You are responsible for participating in the planning of your home health care treatment. You are responsible for providing to the agency any information necessary for processing third party payment of charges for the items and services provided by the agency and/or making arrangements for payment of your bill.
7. You are responsible for understanding the following criteria that, when taken singularly or in any combination, indicate an appropriate basis for discharge from VNA Plus services:
   • The customer establishes residence outside the VNA Plus service area.
   • The services needed by the customer exceed the limitations of
     VNA Plus policies.
   • The services needed by the customer exceed the limitations of the availability of VNA Plus staff.
   • The home setting is one in which the services can no longer be rendered effectively in the best interests of the customer and/or the VNA Plus staff.  This includes environmental factors that endanger the safety of customer and/or VNA Plus staff.
   • The customer and/or the customer’s support system are incapable or unwilling to cooperate or participate in the customer’s care.
   • The customer’s home care needs are met or care is refused.
   • Agency financial limitations are such that the customer services can no longer be funded.
   • There is lack of physician certification/orders.
   • Customer’s account is delinquent for services not covered by insurance or third party.  A delinquent account is defined as at least thirty days past due from the invoice date and the responsible person has refused to make payment arrangements.