Patient First Name

Patient Last Name

Patient Middle Name

Other names used by client (blank if none)

Patient Date of Birth (MM/DD/YYYY)

Patient Sex Patient Sex Male Female

Patient or representative email address (Required for patient portal - also federal requirement for patient document delivery. representative name and phone number also acceptable)

Does patient have health sense 65? Does patient have health sense 65? Yes No

Does patient have True Blue? Does patient have True Blue? Yes No

Does patient have Secure Blue? Does patient have Secure Blue? Yes No

Does patient have Flexi Blue? Does patient have Flexi Blue? Yes No

Does patient have Sterling? Does patient have Sterling? Yes No

Does patient have Humana? Does patient have Humana? Yes No

Does patient have Medicare Complete? Does patient have Medicare Complete? Yes No

Does patient have Secure Horizons Direct? Does patient have Secure Horizons Direct? Yes No

Does patient have Deseret Mutual? Does patient have Deseret Mutual? Yes No

Does patient have Regence Med Advantage? Does patient have Regence Med Advantage? Yes No

Consent for Care - Check all that apply Consent for Care - Check all that apply Nurse PT OT SLP SW Aide Other

Nursing Frequency - (If Unknown Please Write EVAL)

PT Frequency - (If Unknown Please Write EVAL)

OT Frequency - (If Unknown Please Write EVAL)

SLP Frequency - (If Unknown Please Write EVAL)

SW Frequency - (If Unknown Please Write EVAL)

Aide Frequency - (If Unknown Please Write EVAL)

Other - Specify (If Frequency is Unknown Please Write EVAL)

Is the patient a participating member of and HMO (Health Maintenance Organization) Is the patient a participating member of and HMO (Health Maintenance Organization) Yes No

Expected Payer Source(s) for patient home care services include: Expected Payer Source(s) for patient home care services include: Medicare Medicaid Other

Other Payer Source:

ADVANCE DIRECTIVES - Patient currently has: ADVANCE DIRECTIVES - Patient currently has: Living Will DNR/POST Health Care Power of Attorney

ADVANCE DIRECTIVES - Copies Requested ADVANCE DIRECTIVES - Copies Requested Yes No

MEDICARE CONSIDERS YOU HOMEBOUND IF: MEDICARE CONSIDERS YOU HOMEBOUND IF: You experience a normal inability to leave your home; It requires considerable and taxing effort to leave your home; Absences from home are infrequent, of short duration, or are for medical treatment.

Do you have a condition that restricts your ability to leave home except with the aid of supportive devices and assistance of another person? Do you have a condition that restricts your ability to leave home except with the aid of supportive devices and assistance of another person? Yes No

Are absences from the home infrequent, of short duration and usually to receive medical care not available in the home? Are absences from the home infrequent, of short duration and usually to receive medical care not available in the home? Yes No

Are there a combination of factors such as architectural barriers, stairs, cognitive or safety issues that result in an inability to leave home without assistance? (Psychiatric problems, cognitive deficits blindness, organic brain disorder, Alzheimer’s disease, etc. could qualify) Are there a combination of factors such as architectural barriers, stairs, cognitive or safety issues that result in an inability to leave home without assistance? (Psychiatric problems, cognitive deficits blindness, organic brain disorder, Alzheimer’s disease, etc. could qualify) Yes No

Is leaving home mentally contraindicated? Is leaving home mentally contraindicated? Yes No

Patient has received the following document(s) from All Care Health Solutions Patient has received the following document(s) from All Care Health Solutions ADVANCE DIRECTIVE FOR HEALTH CARE PATIENT BILL OF RIGHTS AND HIPAA INFORMATION

Signed a Durable Power of Attorney for Health Care Signed a Durable Power of Attorney for Health Care Yes No

Signed a Living Will or Directive to Physicians Signed a Living Will or Directive to Physicians Yes No

Patient authorizes All Care Health Solutions to release information and medical records regarding my medical health, mental health, and chemical dependency, as specifically requested, with respect to my treatment Patient authorizes All Care Health Solutions to release information and medical records regarding my medical health, mental health, and chemical dependency, as specifically requested, with respect to my treatment Yes Including HIV/AIDS information Not Including HIV/AIDS information

Patient authorizes All Care Health Solutions and its representatives to have written and / or verbal contact with the following individuals: (Select any that apply, or leave blank) Patient authorizes All Care Health Solutions and its representatives to have written and / or verbal contact with the following individuals: (Select any that apply, or leave blank) Guarantor Father Mother Spouse Financial Institution Employer Administrative Assistant Significant Other

Guarantor

Father

Mother

Spouse

Financial Institution

Employer

Administrative Assistant

Significant Other

TB SCREENING UPON ADMISSION TB SCREENING UPON ADMISSION

Have you had a cough for two or more weeks duration? Have you had a cough for two or more weeks duration? Yes No

Have you had Fever? Have you had Fever? Yes No

Has your cough been productive of sputum? Has your cough been productive of sputum? Yes No

Has your cough been blood stained? Has your cough been blood stained? Yes No

Have you had night sweats? Have you had night sweats? Yes No

Have you had lethargy? Have you had lethargy? Yes No

Have you had unintentional weight loss? Have you had unintentional weight loss? Yes No

Do you or your family have TB now, or a history of TB? Do you or your family have TB now, or a history of TB? Yes No

Have you had Weakness? Have you had Weakness? Yes No

TB Screening Comments:

MEDICARE SECONDARY PAYER WORKSEHEET MEDICARE SECONDARY PAYER WORKSEHEET

Are any changes needed to the Medicare Secondary Payer Worksheet as listed in the hard copy? Are any changes needed to the Medicare Secondary Payer Worksheet as listed in the hard copy? Yes No

Section A 1) Section A 1) Yes, Black lung Benefits No, Go to 2

Black Lung benefits begin date (MM/DD/YYYY)

Section A 2) Section A 2) Yes, Government program will be primary No, Go to 3

Section A 3) Section A 3) Yes, DVA is primary No, Go to 4

Section A 4) Section A 4) Yes, Related to work related accident No, Go to Section B

Date of work related injury/illness (MM/DD/YYYY)

Section B 1) Section B 1) Yes, non-work related illness/injury No, Go to Section C

Section B 2) Type of accident? Section B 2) Type of accident? Automobile Non-Automobile Other

Section B1) Date of accident (MM/DD/YYYY)

Section B 3) Another party responsible? Section B 3) Another party responsible? Yes, Complete Payer info No, Go to section C

Section C 1) Section C 1) Age, Go to Section D Disability, Go to Section E ESRD, Go to Section F

Section D 1) Age - Currently Employed? Section D 1) Age - Currently Employed? Yes, Currently Employed No, Retired No, Never Employed

Date of Retirement (MM/DD/YYYY)

Section D 2) Age - Spouse Currently Employed? Section D 2) Age - Spouse Currently Employed? Yes, Spouse Currently Employed No, Spouse Retired No, Spouse Never Employed

Spouse Date of Retirement (MM/DD/YYYY)

Section D 3) Group Health Plan on current employment? Section D 3) Group Health Plan on current employment? Yes No, Medicare is Primary

Section D 4) Employer GHP employ more than 20 employees? Section D 4) Employer GHP employ more than 20 employees? Yes No, Medicare is Primary

Section E 1) Disability - Currently Employed? Section E 1) Disability - Currently Employed? Yes, Complete Payer Info No, Complete Date of Retirement No, Never Employed

Date of Retirement (MM/DD/YYYY)

Section E 2) Disability - Spouse Currently Employed? Section E 2) Disability - Spouse Currently Employed? Yes, Complete Payer Info No, Complete Date of Retirement No, Never Employed

Spouse Date of Retirement (MM/DD/YYYY)

Section E 3) Group Health Plan on own or family members plan? Section E 3) Group Health Plan on own or family members plan? Yes No, Medicare is Primary

Section E 4) Covered under GHP of a family member other than spouse? Section E 4) Covered under GHP of a family member other than spouse? Yes, Complete Payer info No

Section E 5) Employer GHP employ more than 100 employees? Section E 5) Employer GHP employ more than 100 employees? Yes, GHP Primary, Complete payer info No, Medicare is Primary

Section F 1) ESRD - Do you Have GHP Coverage? Section F 1) ESRD - Do you Have GHP Coverage? Yes, Complete Payer Info No, Medicare is Primary

Section F 2) Have you received a kidney transplant? Section F 2) Have you received a kidney transplant? Yes, Complete Date of Transplant No

Section F 2) Transplant Date (MM/DD/YYYY)

Section F 3) Have you received maintenance dialysis treatments? Section F 3) Have you received maintenance dialysis treatments? Yes No

Section F 3) Date Began (MM/DD/YYYY)

Section F 4) within 30 month coordination period? Section F 4) within 30 month coordination period? Yes No, Medicare is Primary

Section F 4) coordination period start date (MM/DD/YYYY)

Section F 5) entitled to Medicare on ESRD basis of age or disability? Section F 5) entitled to Medicare on ESRD basis of age or disability? Yes No

Section F 6) entitled to Medicare based on ESRD? Section F 6) entitled to Medicare based on ESRD? Yes, Stop. GHP is primary through 30M CP No, Initial entitlement based on age or disability

Section F 7) Working aged or disability MSP provision apply? Section F 7) Working aged or disability MSP provision apply? Yes, Stop. GHP is primary through 30M CP No, Medicare is primary

PRIMARY PAYER INFORMATION PRIMARY PAYER INFORMATION

Employer (Patient)

Employer Address

Employer (Spouse)

Spouse Employer Address

Insurer/GHP

Insurer/GHP Address

Policy ID Number

Group ID Number

Membership Number

Name of Policy Holder

Relationship To Patient

Is patient on life support equipment? Is patient on life support equipment? Yes No

Does patient require special transportation or equipment to leave the home? Does patient require special transportation or equipment to leave the home? Yes No

If yes, what is needed: wheelchair, van, ambulance, Hoyer lift, other?

MEDICAL SUPPLIERS (Check all that apply) MEDICAL SUPPLIERS (Check all that apply) NORCO (208-344-0299) Procare (208-322-5055) Bennett (208-327-8888) Adderson (208-895-0033) Medeco (208-429-1138) Other

Other Medical Supplier

UTILITIES (Check all that apply) UTILITIES (Check all that apply) Idaho Power (800-488-6151) Utah Electric (801-998-2527) Intermountain Gas (208-377-6840)

Physician Name

Physician Phone

Pharmacy Name

Pharmacy Phone

Neighbor Name

Neighbor Phone

Emergency Management Office (Check which applies) Emergency Management Office (Check which applies) Ada County (208-577-3000) Canyon County (208-454-7271) Payette County (208-642-6000)

Priority Level (Select One) Priority Level (Select One) LEVEL I: HIGH PRIORITY. Patients in this priority level need uninterrupted services. In the case of a disaster or emergency, every possible effort must be made to see this patient. The patient's condition is highly unstable and deterioration or inpatient admission is highly possible if the patient is not seen. Examples include patients who require life sustaining equipment or medication, those who need highly skilled wound care, and unstable patients who have no caregiver or informal support to provide care. LEVEL II: MODERATE PRIORITY. Services for patients at this priority level may be postponed with telephone contact. A caregiver can provide basic care until the emergency situation improves. The patient's condition is somewhat unstable and requires care that should be provided that day but could be postponed without harm to the patient. LEVEL III: LOW PRIORITY. The patient may be stable and has access to informal support to provide care. The patient can safely miss a scheduled visit if basic.

STATEMENT AFFIRMATIONS - PLEASE REVIEW ALL WITH PATIENT STATEMENT AFFIRMATIONS - PLEASE REVIEW ALL WITH PATIENT

1. I have read the "Name of Beneficiary of Health Insurance" form and its contents, and further more acknowledge that if I have a Medicare HMO or Advantage Plan, I am responsible for any co-pays and/or coinsurance costs. 1. I have read the "Name of Beneficiary of Health Insurance" form and its contents, and further more acknowledge that if I have a Medicare HMO or Advantage Plan, I am responsible for any co-pays and/or coinsurance costs. Yes

2. I have read the “Consent for Care”, “Patient Rights and Responsibilities”, which includes the State Home Health Hotline phone number, “Release of Information”, “Liability for Payment”, “Consent to Photograph”, “Statement of Patient Privacy Rights/Notice About Privacy”, “Privacy Act Statement – Health Care Records”, “Notice of Privacy Practices”, “Your Rights as a Patient to Make Medical Treatment Decisions”, “Advance Directives” and its contents. 2. I have read the “Consent for Care”, “Patient Rights and Responsibilities”, which includes the State Home Health Hotline phone number, “Release of Information”, “Liability for Payment”, “Consent to Photograph”, “Statement of Patient Privacy Rights/Notice About Privacy”, “Privacy Act Statement – Health Care Records”, “Notice of Privacy Practices”, “Your Rights as a Patient to Make Medical Treatment Decisions”, “Advance Directives” and its contents. Yes

3. I have read the "Medicare definition of Homebound" and its contents. 3. I have read the "Medicare definition of Homebound" and its contents. Yes

4. I have read “Advance Directive for Health Care”, “Patient Bill of Rights and HIPAA Information” and its contents. 4. I have read “Advance Directive for Health Care”, “Patient Bill of Rights and HIPAA Information” and its contents. Yes

5. I have read “Authorization to Release Information for Payment and Reimbursement Purposes” and its contents. 5. I have read “Authorization to Release Information for Payment and Reimbursement Purposes” and its contents. Yes

6. I have read “Authorization for Release of Medical Information” and its contents. 6. I have read “Authorization for Release of Medical Information” and its contents. Yes

7. I have read “TB Screening upon Admission” and its contents. 7. I have read “TB Screening upon Admission” and its contents. Yes

8. I have read “Medicare Secondary Payer Worksheet” and its contents. 8. I have read “Medicare Secondary Payer Worksheet” and its contents. Yes

9. I have read the "Pinnacle Quality Insight survey notice" and its contents. 9. I have read the "Pinnacle Quality Insight survey notice" and its contents. Yes

10. I have received the Quality Improvement Organization (QIO) contact information (Kepro: 888-317-0891). 10. I have received the Quality Improvement Organization (QIO) contact information (Kepro: 888-317-0891). Yes

11. I have read the "Emergency Preparedness Plan" and the "Admission/Transfer/Discharge Criteria". 11. I have read the "Emergency Preparedness Plan" and the "Admission/Transfer/Discharge Criteria". Yes

ELECTRONIC SIGNATURE - (THIS SECTION MUST BE COMPLETED BY PATIENT) ELECTRONIC SIGNATURE - (THIS SECTION MUST BE COMPLETED BY PATIENT) I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing.

Patient/Representative First Name

Patient/Representative Last Name

Electronic Signature Date (MM/DD/YYYY)

Representative Relationship to Patient

Reason Patient is Unable to Sign

Agency Staff - First Name

Agency Staff - Last Name

Agency Staff - Title

Staff Member Email Address (to receive copy of packet)