Parent/Guardian Name

Patient Name

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.

Enter PDN Hours

Enter PT Schedule

Enter OT Schedule

Enter SLP Schedule

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.

Please Select Primary Insurance AETNA Amerigroup BCBS Federal BCBS of Texas BCBS of Michigan BCBS Medicaid BCBS Illinois CIGNA Community First Health Plan GEHA Humana Molina Healthcare, Inc. Rightcare from Scott & White Health Plan Seton Health Plan Superior HealthPlan Network Texas Medicaid Healthcare Partnership Tricare Texas Childrens Health Plan UHC Commercial N/A

Policy #:

Please Select Secondary Insurance AETNA Amerigroup BCBS Federal BCBS of Texas BCBS of Michigan BCBS Medicaid BCBS Illinois CIGNA Community First Health Plan GEHA Humana Molina Healthcare, Inc. Rightcare from Scott & White Health Plan Seton Health Plan Superior HealthPlan Network Texas Medicaid Healthcare Partnership Tricare Texas Childrens Health Plan UHC Commercial N/A

Policy #:

Please Select Tertiary Insurance AETNA BCBS Federal BCBS of Texas BCBS of Michigan BCBS Medicaid BCBS Illinois CIGNA Community First Health Plan GEHA Humana Molina Healthcare, Inc. Rightcare from Scott & White Health Plan Seton Health Plan Superior HealthPlan Network Texas Medicaid Healthcare Partnership Tricare Texas Childrens Health Plan UHC Commercial N/A

Policy #:

Self Pay:

Per Visit

Per Hour

N/A

Payment amount

Co-payment amount

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

Medical Power of Attorney name

Phone Number

Patient is a minor and unable to sign.

Printed Name

date_range Date