Page 90 - Business Development Orientation Binder

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NOTIFICATION OF NON-ACCEPTANCE TO VNSNY HOME CARE SERVICES

PATIENT:

DOB:

MD/REFERRER:

FAX NUMBER:

MRN/CASE#:

REFERRAL DATE:

The Visiting Nurse Service of New York Home Care has determined that the above patient
cannot be taken under care because:
| j The patient is not under care of a physician or medical facility that is willing to develop,
approve and regularly review the medical treatment plan.
I I The agency does not have sufficient properly trained staff to provide the types and level of
care as required by the physician.
• Care requested is not consistent with V N S N Y Home Care Patient Service Policies and/or
V N S N Y Home Care Medical Relationship Policies.

Specifically:

I j A reasonable emergency or alternate plan to ensure that patient safety and essential needs
will be met in an emergency situation or in the absence of agency personnel is not in place.
I~l The patient does not reside within an area serviced by V N S N Y Home Care.
The patient and/or designated other are not able, willing and/or available to participate and
cooperate in carrying out the plan of care.
I j The patient and/or family are not willing to accept agency personnel without regard to race,
color, creed, sex, age or national origin.
I | The safety of agency personnel cannot be maintained while providing needed services.
| | The patient and/or family are not willing to provide V N S with insurance/financial information
so that care can be free of charge as necessary.
I I The patient can not be adequately and safely cared for at home for the following reason(s):

Signature: P h o n e : (212) 824-7226 Date: 12-11-2015

Title: R e g i o n a l Intake