Self Referral
AGREEMENT AND CONSENT
Terms of Agreement and Medical Consent
I understand that by signing this Agreement , I authorize the provision of products and services to me by Preferred Excellent Care ("PEC"). I also understand that I am to remain under the medical care of my attending physician throughout the course of my treatment. My attending physician has explained the nature, risks and possible complications and consequences of home infusion therapy to me, and I hereby consent to the therapy. I know that the provision of medical services is not an exact science and I have neither asked for nor received any guarantees as to the results that will be obtained.
I understand that if I request additional home health services, other than home infusion therapy, PEC may refer me to another provider who is not owned or operated by PEC. I will under no circumstances hold PEC responsible or liable for the services furnished by another provider or for the consequences of any services furnished by another provider, nor will I hold PEC responsible or liable for giving me the names of other home care providers.
Medical Information Authorization
Pursuant to the California Confidentiality of Medical Information Act, (Cal. Civil Code & 56 et seq.), I authorize my hospital, physician, nursing agency, or other health care provider to release to any agent, designee or representative of PEC any and all records pertaining to my medical history, and any services rendered or treatment given to me.
I also authorize PEC and the Joint Commission for the Accreditation of Health Care Organization (JCAHO) to examine my medical records for the purpose of quality assurance compliance.
Assignment of Insurance Benefits
I authorize direct payment to PEC of any insurance benefits for products and/or services provided by PEC. I authorize my insurance company (ies) to furnish to any agent, designee or representative of PEC any and all information pertaining to my insurance benefits and status of claims submitted by PEC for services rendered. I assign to PEC any and all of my rights to pursue any remedy that might accrue to me as a result of the failure of my insurer(s) to reimburse PEC for products or services rendered under this Agreement.
Acknowledgment of Financial Responsibility
I understand that I am financially responsible for all products and services provided by PEC that are for any reason whatsoever not reimbursed by my insurance, or Medicare/ MediCal/CalOptima. For MediCal/CalOptima and Medicare patients: I understand that I am financially responsible for the monthly share of cost required by MediCal/CalOptima and Medicare. Any claim or controversy arising in relation to this Agreement or in relation to PEC�s provision of products or services will be settled by arbitration in accordance with the arbitration rules of the American Arbitration Association. The decision of the arbitrator(s) shall be binding and conclusive on the parties, and judgment on the award rendered may be entered in any court having jurisdiction. If any action or proceeding is brought in relation to the products or services provided by PEC under this Agreement or to enforce or interpret the provisions of this Agreement, the prevailing party shall be entitled to recover reasonable attorneys� fees from the other party.
Return Goods Policy
I understand that drugs and ancillary supplies dispensed to me may not be returned to PEC for credits, and in many cases the ancillary supplies and equipments are properties of PEC. They must be returned at the end of the service in good condition or I will be financially responsible for lost or damaged equipment resulting from misuse.
This Agreement shall be binding on and insure to the benefit of the heirs, executors, administrators, successors, and assigns of both parties to this Agreement.
PATIENT�S RIGHTS AND RESPONSIBILITIES
Our pharmacy normal business hour is Monday through Friday from 9AM to 6PM. We do have a pharmacist on call for after hours emergency for services related to home care/IV infusion services. However, please call:
Life threatening situation 911
Your home health agency for nursing related issue (name/phone): ____________________________________
Your attending physician for the prescribed therapy (name/phone): ____________________________________
As a client you have the right to:
- Consult with your home care pharmacist in regard to your medications, catheter care and infusion therapy.
- Receive this notice before the initiation of care
- Be treated with dignity, consideration and respect by trained professional staff
- Have your person and property treated with present and privacy
- Voice grievances regarding care or lack of respect for property without being subject to discrimination or reprisal. once reported, the pharmacist in charge of the pharmacy will attempt to revolve the problem with written response within 15 days from the initial call. If patient is not satisfied with the resolution, a complaint may be made to The California Department of Health services, Licensing and Certification, Orange County District Office 2390 E. Orangewood Avenue #400, Anaheim, CA 92806 or to phone number (800) 228-5234.
- Know in advance if you will be responsible for any cost other than your own co-payment and yearly deductible that are pre-determined by your medical insurance policy and medicare/mediCal regulations.
- Be informed by a physician of your medical condition and be given an opportunity to participate in designing care plan for your needs and updating it as your condition changes.
- Expect confidentiality of all information related to your care, within regulations.
- Refuse treatment and to be told the consequences of your action.
- Be informed within a reasonable time of anticipated termination of service.
- Have your family taught about your illness so that you can help yourself and the family can help you.
- Choose freely among available providers and to change providers after services have begun, within the limits of health insurance.
- Remain under a doctor�s care while receiving pharmacy services
- Provide the pharmacy with a complete and accurate history and any medication you are taking
- Provide the pharmacy all request insurance and financial records
- Sign the Agreement and Consent Form
- Participate in your plan of care, coordinate and cooperate with your doctor, home health nurse and other caregivers
- Read the drug information and cath care information given to you
- Treat pharmacy personnel with respect and consideration
- Advice the pharmacy of any problems or dissatisfaction with the care, without being subject to discrimination or reprisal
- Notify the pharmacy when unable to accept a delivery or there is change in address or therapy.
- Notify the pharmacy to pick up unused equipment and sharp container
- Notify pharmacy at hospitalizations
- Provide a safe home environment in which your care can be given
- Comply with your therapy as ordered
- Be financially responsible for PEC equipment if it is not returned, or if damaged from negligence or misuse