AHC Informed Consent Form

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First Name

Last Name

Services

Address Street

City

State

Zip Code

Contact

Personal Health Information Disclosure:

(Required)

I understand that by giving my consent I am permitting my personal health information to be disclosed to persons who will be involved in my treatment; it may also be used for payment and operational purposes as allowed by law. I reviewed and received a copy of the "Notice of Privacy Practices" before signing this consent, and Aquinas Healthcare reserves the right to change the terms of the notice of privacy practices and make changes available to me.

(Required)

I may request to place additional restrictions on the access of my personal health information for treatment, payment, or health care operational purposes, and I understand that Aquinas Healthcare may not be able to comply with this request if they have already acted on reliance on this signed Informed Consent document.

I request the following restrictions regarding my personal health information:

Restrictions

(Required)

I consent to the use of my identifiable personal information necessary for the continuity of my care or which may be of benefit in maintaining or improving my health with the understanding that Aquinas Healthcare will not provide such information to others for marketing, fundraising, or similar purpose without my consent.

(Required)

I understand that I, or my representative, upon request may inspect, request correction of and obtain information from my patient record held by Aquinas Healthcare.

(Required)

I may revoke this consent in writing at any time except to the extent that Aquinas Healthcare has already acted in reliance on this consent.

Client/Legal Representative Signature (state relationship)

Date

MM slash DD slash YYYY

Consent for Service:

I request and agree to have home care services provided in my home, or current residence, by Aquinas Healthcare. I authorize Aquinas Healthcare employees to enter my place of residence to assess, supervise, and carry out the agreed upon service.

(Required)

I understand that my consent is voluntary, and I have the right to accept or refuse any service as I choose. I have been informed of the hazards of my choice, such as falls, and that certain other risk and hazards in home care are beyond the control of Aquinas Healthcare

I have a Power of Attorney and will provide a copy to Aquinas Healthcare immediately

POA Cell Number

POA Email

Payment for Services and Personal Insurance Coverage:

(Required)

I understand that Aquinas Healthcare is a Private Pay Health Care Service Firm. I am responsible for paying Aquinas Healthcare directly for all services rendered. I acknowledge that I will be responsible for submitting all required documentation to my insurance providers for any reimbursement under the terms on my insurance policy. Aquinas Healthcare will not become the beneficiary of my insurance reimbursements. Additional fees may be charged if the Client requests additional RN or supervisory visits by management, which are in line with the current RN rates.

(Required)

I understand and agree with the following initial Aquinas Healthcare rates

Live In CHHA is ________Day

Initial RN Assessment Fee of $150 and takes approximately 2 hours. The family provides the Live In Aides free room and board. Any special dietary needs will be communicated. Aquinas will provide a temporary Aide when the assigned Aide needs time off. Other rates and details: Hourly CHHA Rates are $___/Hour, based on the number of hours. Any Nurse visits in addition to the 60 day visit or due to the patient’s change in status requested by the client or their family will be charged at the hourly rate of $75/hour. Please provide 48 hours’ notice when cancelling services. Invoices are processed every 2 weeks. Rate increases will be communicated in advance.

Hourly Aide(s) at $_______ per Hour

Live-In Aide at $________ per Day

Other: ____________

(Required)

I understand rates are subject to change and may increase over time.

Due to the current caregiver shortage, we cannot guarantee Caregiver availability, and the schedules may fluctuate, and we will operate on a best effort basis. Home Health Aide CHHA, shifts of 8-hours or less are often difficult to cover simply due to caregiver shortage. The following Holidays are charged at 150% of the normal rate: Memorial Day, July 4 th, Labor Day, Thanksgiving, Christmas & New Year’s Day. Please provide 48 hours’ notice when cancelling or suspending services.

(Required)

I agree to pay late fee interest on all open balances, once an invoice is Past Due. The current rate of late interest is 1.5% per month (18% APR). I agree to pay all costs incurred by Aquinas Healthcare to collect payments for services/supplies provided, plus attorney’s fees, court cost, collection agency fees and other expenses. If payment is not received by Aquinas Healthcare in a timely manner, they may terminate services.

I will complete the attached ACH Authorization Form. ACH clients do not need to provide a security deposit or their credit card information. I will be responsible for any bank fees Aquinas Healthcare incurred because of a rejected or reversed ACH payment (i.e.) incorrect account info, bank account changes or my financial institution fails to process a payment. I agree to update Aquinas Healthcare if any of my financial information changes.(Required)

I want to pay via ACH. (We strongly encourage ACH payment)

I agree to provide my credit card info below as a security deposit.(Required)

I want to pay via Check.

I agree to provide my credit card info below as a security deposit.

Rates will increase by 4% to cover the third-party processing fees. Below is my credit card info for my security deposit and all invoices. I understand that the credit card I provide may be charged for all unpaid balances 7 days after services are provided.(Required)

I want to pay all invoices via Credit Card.

I will submit the required documents to my LTC Insurance claims department for my reimbursement. I will pay Aquinas Healthcare directly regardless of my LTC insurance reimbursements. In some instances, Aquinas Healthcare can submit your documentation directly to your LTC insurance company and additional fees typically apply for this processing.(Required)

I have Long Term Care (LTC) Insurance.

Below is my credit card information for my security deposit. I acknowledge that my credit card may be charged if my account is 30 days past due. The credit card processing fees apply as noted above.

If you prefer not to send your payment details electronically, you can call our office at (973) 467-8502 Mon – Fri, 9am – 5pm to provide our staff with your payment details

Bank Routing Number

Bank Account Number

Bank Card Number

Expiration Date

CVV

(3 digits on back or 4 digits on front of American Express)

Name on Credit Card

Billing Address: (Include Zip Code)

Invoices are typically processed every two weeks.

Please Email my invoices to

Please Mail my invoices to

Client’s Rights and Responsibilities and Grievance Procedure

(Required)

I acknowledge receipt of the Home Care Bill of Rights and Responsibilities document. I understand my rights and responsibilities as they have been given to me. I have also received the Aquinas Healthcare’s Grievance Procedure. I understand how to file a complaint about care, treatment, discontinuation of service and to appeal the decisions of Aquinas Healthcare. I acknowledge that prior to signing this, I have asked all additional questions, and my questions have been answered to my satisfaction. I realize that it is my responsibility to raise any questions regarding the services provided by Aquinas Healthcare.

(Required)

I recognize the rights of Aquinas Healthcare as a N.J. Licensed Health Care Service Firm and fully insured employer. I agree not to employ any Aquinas Healthcare employee or former employee directly or indirectly for a period of 1 year from when Aquinas Healthcare’s services terminate. This may be waived if Aquinas Healthcare provides me with written approval. This “No Compete” applies to me, my family, or representatives. If I violate this condition, I agree to pay Aquinas Healthcare a fee equal to $75.00 per day, for each day I have directly employed any individual who was introduced to me and employed by Aquinas Healthcare. I understand that it is illegal for a licensed Certified Home Health Aide to work privately without the direct supervision of a Registered Nurse. I understand that any Licensed Healthcare worker in New Jersey can lose their individual license and be banned from the industry for working privately. I agree to pay all reasonable costs of collections and reparations, including attorney’s fees, court cost and any other related expenses to Aquinas Healthcare resulting from a violation of the terms of this agreement as well as any lost wages or legal fees for the Employee.

Advanced Directives

(Required)

Yes, I have formulated an Advance Directives, I have been advised to give a copy to my Physicians, Aquinas Healthcare, and any other Healthcare providers. I understand that I can make changes or cancel my Advance Directive at any time in writing. I acknowledge that my Advanced Directives or updates to my Advanced Directives can only be followed when each provider is provided a copy.

(Required)

A copy of my Advance Directives has been provided to Aquinas Healthcare.

(Required)

No I do not have Advance Directives. Advance Directives have been explained to me and I understand that Aquinas Healthcare does not require that I develop Advance Directives to receive care. If I create Advance Directives, I will provide a copy to Aquinas Healthcare.

Consumer’s Guide

(Required)

I acknowledge receipt of the “New Jersey Board of Nursing’s Consumer Brief “. I understand that I can find a copy of “A Consumer’s Guide to Homemaker-Home Health Aide Services” at www.AquinasHealthcare.com. This is published by the N.J. Office of the Attorney General, Division of Consumer Affairs, Board of Nursing. I have waived the right to receive a paper copy of this material 24 hours prior to the provision of services; however, this information was received by me or my representative before services began.

(Required)

I can also find a copy of the Consumer’s Guide by visiting: https://www.njconsumeraffairs.gov/hhh/Documents/A-Consumers-Guide-to-Homemaker-Home-HealthAides.pdf. If I have any issues, I will call the Aquinas Healthcare Office for a hard copy of this guide.

(Please Initial)

Danielle’s Law

In accordance with Danielle’s Law, employees of the Company are required to call 911 in life threatening emergencies. As defined in the law, “life-threatening emergency means a situation in which a prudent person could reasonably believe that immediate intervention is necessary to protect the life of a person receiving services or to protect the lives of other persons in the home from an immediate threat or actual occurrence of a potentially fatal injury, impairment to bodily functions or dysfunction of a bodily organ or part.” In compliance with this law, Aquinas Healthcare’s employees are instructed to call 911 if they feel there is an emergency in the home or client’s residence, regardless of the family’s wishes. Failure by any health care professional to call 911 in a life-threatening emergency includes monetary fines between $5,000 - $25,000, revocation of any individual professional license(s) or other authorization to practice as a health care professional.

Business Ethics and Corporate Compliance

Aquinas Healthcare stands for the highest level of integrity and ethical standards in relation to business practices and direct service to the people and communities served by our organization. Therefore, it is the policy of Aquinas Healthcare to deliver service and conduct its business in compliance with all applicable laws, regulations, and ethical standards and to have established mechanisms to ensure conformity with laws, regulations, program requirements and guidelines, and ethical business practices by all its employees.

Should you at any time observe an Aquinas Healthcare employee doing anything illegal or fraudulent or be asked to do something you believe to be illegal, fraudulent, or unethical by the Aquinas Healthcare employee please call Aquinas Healthcare’s office at (973) 467-8502 and ask to speak with the company’s President or Vice President.

(Required)

I agree that all non-Aquinas Healthcare Caregivers or licensed professionals involved in my care, are prohibited from using, removing, or changing any Aquinas Healthcare’s documentation. Non-Aquinas Caregivers will be responsible to report and document any client status change, as soon as their shift begins. If there is a change in status during a Non-Aquinas Healthcare shift, that Caregiver must report all changes to client’s family immediately and the Aquinas employee who is working next. All Aquinas Healthcare employees report only to the Aquinas Healthcare’s Nurse, Manager or Supervisor. All Aquinas Healthcare employees are licensed by the State of N.J. Aquinas Healthcare’s staff will not assume responsibility or liability for any NonAquinas Healthcare Caregivers actions, inactions, care, negligence, or failure to immediately report and document a client change in status or condition.

(Required)

I certify that I have read and understand the above statements. I agree and consent to all conditions and terms and have received a copy thereof. I am the client or duly authorized by the client as the client's agent to execute the above terms. I acknowledge and agree that the responsibilities regarding the non-compete payment for services, late fees or penalties apply to my family, POA or any future agent. Aquinas Healthcare has the right to update their Terms of Service, and I will be bound by the new terms or have the right to terminate services once they are furnished in writing. If the client/person authorizing these services has any cognitive impairment such as dementia, Alzheimer’s or TBI, this must be signed by a POA or representative. The individual signing below is financially responsible for making payments to Aquinas Healthcare as per these terms or updated terms.

Patient/Legal Representative Signature (state relationship)

Date

MM slash DD slash YYYY

Aquinas Healthcare’s ACH Authorization Form

I, _______________________________ authorize Aquinas Healthcare (“the Company”) to process recurring

(Payer’s Full Name)

charges to my checking/savings account. The Company will process ACH payments for the amount on each invoice. The information I provide below is on each paper bank check used for payments. This form authorizes the Company to process ACH payments and confirms my bank account information. The Company will store all client information safely in compliance with the U.S. Red Flag Rules. The Company will send each invoice at the end of each service period via email or USPS. After 5 calendar days, the Company will process the ACH payment for the amount due on the latest invoice. These processed payments will appear in the client’s bank account as “ACH Debits”. I understand that no additional prior notification will be provided prior to any ACH transaction. ACH credits are processed in the same manner and client’s security deposit balances will be credited after 5 calendar days. I will call the Company’s office to reconcile charges on any invoice amount I believe should be adjusted. ACH payments reduce paper waste, limit fraud risk, minimize human errors, and eliminate late fees and collections. Invoices will be sent by the Company after all services have been provided. If at any time my bank account information changes, I will notify the Company immediately, providing them the details for my new bank account or alternate payment method. These payments are for healthcare services or technology solutions Aquinas Healthcare has provided me or my family member. If services are cancelled, the final ACH payment will be processed 5 calendar days after the invoice is sent.

Billing Information for Person or Trust on the Bank Account

Street Address

Phone

City, State, Zip

Bank Details

Checking

Savings

Name(s) on or Title of Account

Bank Name

Routing #

Account #

(Required)

I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify Aquinas Healthcare immediately and then in writing of any changes in my account information or termination of this authorization at least 5 days prior to the next invoice processing date. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the Company processes them. If an ACH transaction is rejected for Non-Sufficient Funds (NSF) in my account or my Bank freezes my account, I understand that the Company may attempt to process the ACH payment again within 30 days. I also agree to pay the $30 NSF fee for each time the ACH transaction is attempted by the Company and fails. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of Federal and State law. I certify that I am an authorized user of the bank account noted above and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.

Signature

Date

MM slash DD slash YYYY

Print Name

AHC Informed Consent Form

Personal Health Information Disclosure:

Consent for Service:

Payment for Services and Personal Insurance Coverage:

Client’s Rights and Responsibilities and Grievance Procedure

Advanced Directives

Consumer’s Guide

Danielle’s Law

Business Ethics and Corporate Compliance

Aquinas Healthcare’s ACH Authorization Form

Billing Information for Person or Trust on the Bank Account

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