By my signature below, I acknowledge that I have reviewed and been provided a copy of PHC’s Company Admission Policies and Procedures, which contains important information of PHC’s practices including the policies regarding:

• insert_drive_filePHC Client Rights and Responsibilities
• insert_drive_filePHC Notice of Privacy Practices
• insert_drive_filePHC Pediatric Home Safety Checklist
• insert_drive_fileAAP Family Readiness for Disasters
• insert_drive_fileAdvance Directive

I have also been given the opportunity to review, discuss and sign:

• insert_drive_fileConsent of Service/Release of Records
• insert_drive_fileClient Choice Statement
• insert_drive_fileClient Non-Solicitation

I understand that at any time, and for any reason, I can choose to change my services to another healthcare provider. I attest that I initiated contact with PHC and was never directly, nor indirectly, solicited for services. I give the licensed agency permission to provide Home Health Services and accept treatment from the agency. Furthermore, I authorize the release of Patient Health Information to:

• Physicians
• Facilities
• Payer Sources
• Early Childhood Intervention Programs
• Independent School District’s, Regulatory and Consulting Organizations as appropriate

I acknowledge it is my right and responsibility to be involved in the care of my child, voice complaints to administrator or appropriate agency representative, and agree to the frequency of services determined by the agency.

Finally, I have been given adequate opportunity to ask questions and receive clarification regarding the policies and procedures set forth by PHC.

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