Page 229 - CHHA Binder 2.3.20

4/11/2019

VNSNY Consent & Acknowledgement Form
For MNP

 If the patient is 18 years old or older and cognitively intact, patient
can sign as an adult.

 Females under the age of 18 years who gave birth are considered
an emancipated minor and can give her own consent.

 If a patient is less than 18 years of age, consent must be signed by
the legal guardian, usually the parent.

 If the child is in foster care, the legal guardian is NEVER the foster
parent.
 Foster parents cannot sign legal consent to provide home care
services.
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Facts About Your Home Care Services and Payment

 Purpose
Written acknowledgement of services

patient will be receiving during
episode of care
 All services other than RN, please
document:
1 visit/week x 1 week for Rehab,
or Social Work
For HHA, indicate the number of
hours, frequency and duration

 Notify patient of liability of payment
Clinicians can review the financial

information of the patient, in
Demographics and Payor Source

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