PHC - Admission Packet
Pediatric Healthcare Connection - Admission Packet

LHHS Consent - Step 1 of 6

Consent for Service / Release of Records

I have been informed that Pediatric Healthcare Connection, referred to in this consent as Agency, is licensed to provide home health services according to the Plan of Care established by the Agency staff and the physician. I accept treatment from Agency. I can call the Agency 24 hours a day regarding my health care at: (855) 268-4098. This is not an emergency line. Call 911 in an emergency. It is the policy of the agency to protect all clinical records against loss, defacement, tampering and use by unauthorized persons. I authorize the agency to release medical information to my physician, the facility of my choice, payer source, Early Childhood Intervention Programs, Independent School Districts or accrediting/regulatory/ consulting organizations, as appropriate. I authorize the release of the Plan of Treatment and Discharge Summary upon my transfer to another health care facility.

Services / Frequency / Rights / Hotline / Procedures

I understand that agency staff will supervise all services. I have received a copy and an explanation of the Bill of Rights.

I understand that it is my right and responsibility to be involved in my care and that I will be informed as to the nature and purpose of any technical procedure. I understand the frequency of services. This frequency may change according to need.

I have been notified of my right to voice a complaint and may direct a complaint to the Administrator or designee at (855) 268-4098. An investigation of the complaint will be initiated within 3 calendar days and resolved within 10 calendar days of receipt.

I may also contact the Texas Health and Human Services (HHS) Consumer Rights and Services (CRS), at 1 (800) 458-9858. The line is open 24 hours a day. This includes a complaint regarding advance directives. Complaints regarding Utilization Review or HMO services can be made directly to Texas Department of Insurance Consumer Protection , PO Box 149091, Austin, TX 78714, at 1 (800) 252-3439.

HIPAA - I have received the Notice of Privacy Practices and consent to the agency's use and/or disclosure of protected health information for payment, treatment and Agency's health care operations.

I have been informed verbally and in writing regarding Agency policy on abuse, neglect and exploitation, agency drug testing and hazardous waste disposal in the home.

I have been informed what to do in an emergency/natural disaster and have received education on completing an emergency preparedness plan for myself and my family. I understand the importance of completing this plan and know that agency staff may assist in this process.

Financial Authorization

I authorize benefits to be made in my behalf. Charges for services will be paid by:

Self Pay:

I will pay any service or supply charge not reimbursed by my insurance company on a monthly basis. I will pay all charges incurred on a monthly basis if I do not have insurance coverage. If a claim is denied for Agency which Agency has submitted on my behalf, I hereby elect not to appeal the denial myself, but I do hereby authorize Agency to resubmit the claim for me and represent me in any negotiations. I authorize Agency to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

I have received information and Agency policy on Advance Directives.

Living Will/Directive to Physician
Hospital DNR
Declaration of Mental Health
Medical Power of Attorney

Client Choice Statement - Step 2 of 6


I, (Patient/Parent/Guardian) understand it is my right to select a healthcare provider of my choice. PHC has informed me if for at any time, for any reason I can choose to change my services to another healthcare provider, it is my right to do so.

I have chosen Pediatric Healthcare Connection to provide the below services:

I request the above services for be transferred from:
to Pediatric Healthcare Connection as of
for the reasons of

Backup Services Agreement - Step 3 of 6


I understand there maybe time when the Agency’s employees or contractors maybe unable to provide scheduled services.
I, the primary caregiver, am willing and able and agree without coercion to be responsible for providing the client’s total care or facilitating/authorizing care by an alternate caregiver.
I agree to the following alternate caregiver who is willing and able to provide some of the client’s daily care:


Release - Step 4 of 6


To whom it may concern,

I, the parent/guardian, hereby authorze the agency, to seek emergency medical treatment for my child should the need arise. I agree that I will at all times provide agency with phone numbers or other information necessary to quickly contact me in such emergency situations. I release the agency of any liability for medical treatment that my child may receive from other medical personnel while in the care of agency emplyee. I further realize that circumstance beyond the control of the agency may arise that may pose a threat of danger or cause harm to my child and I release the agency and the employee from any liability related to these circumstances.

Special medical conditions or drug allergies that emergency medical personnel should be aware of regarding my child.

Acknowledgement - Step 5 of 6


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:

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

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.

Emergency Evacuation Route - Step 6 of 6

Ambulance transfer required

Floor 1
Floor 2

Sign and Date - Step 10 of 10


Please sign and date below. If a PHC representative is not present you may click "Save/Omit" below the signature field.



Admission Completed!


Thank you! All PHC Admission forms have been submitted. We look forward to working with you!