Page 228 - CHHA Binder 2.3.20

4/11/2019

 Purpose

 Obtain consent for care

 Acknowledge release of PHI and liability of payment for services

 Acknowledgement of receipt of opening packet paperwork
 Consent for Wound Photography

 Patient must have capacity to sign
Primary MD can decide capacity


 If patient has capacity but physically cannot sign (motor, visual, cognitive deficit)
another adult relative, Power of Attorney, or Health Care Proxy) may sign
indicating on behalf of patient.
 Document in the Coordination Notes patient-selected or indicate the patient
chooses not to have patient-selected representative

 Document in Coordination Notes all verbal and/or written information given to
patient –selected representative
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VNSNY Consent & Acknowledgement Form

The clinician must:
• identify and document representative OR that patient does not want rep to have notice -
interaction with agency.
• identify and document timely preferred language in the COC notes
• Provide notice to the patient of availability of professional interpretation services

**This must be done at SOC and before completion of 2 nd visit.**

If requested, written notice must be given to the patient-selected representative within
4 business days of initial evaluation visit and documented in the COC note.

Unless:
• Patient indicates that they do not designate a patient-selected representative, or
• Decline having written notice provided to patient-selected representative
• Clinician must document patient’s desire in the Coordination Notes.

 In the event a copy is not available the clinician should document in Coordination Notes: “Patient lacks
capacity to make their own health care decisions and the names of the person(s) identified by the courts
who may exercise the patient’s rights”
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