Page 77 - Rehab 2020

* Staff safety

* Patient/Family willing to accept staff w/o regard for race, sex, age, or disability

* Presence of a physical or cognitive problem

* Patient must demonstrate rehab potential

Medicare Criteria for admission:

* Patient must be homebound

* Care needed must be:

* Skilled
* Intermittent

* Reasonable & Necessary
* Ordered by a physician

Opening Forms

When the patient meets the criteria for admission, the patient is given an Opening Packet that
contains forms for the patient or legal representative’s signature. The signing of opening paperwork
is required for admission to VNSNY. The patient signs the forms electronically but is still able to
sign on paper if needed. The SOC visit will have a required section for Electronic Forms, to be
discussed later.

There are 4 forms that need to be filled out in this section:

VNSNY Home Care Consent and Acknowledgement Signature Form

The purpose of the form is to obtain written informed consent for care and to acknowledge the
release of patient’s medical information to authorized third parties. It also provides written
acknowledgment of consents obtained and receipt of all information provided in the admission
packet (Patient Consent and acknowledgement Form and Facts About Home Care Form.)

The form must be reviewed with the patient and family at the time of admission to VNSNY and
should be signed at the initiation of the SOC visit. The patient must sign the form if they have
capacity to consent to treatment. If the patient lacks capacity, the Health Care Proxy signs the form.
If the patient has capacity but is unable to sign, another adult may sign for him/her indicating that
he or she is signing on behalf of the patient.

Care cannot be delivered without consent. If patient refuses to sign consent form, no further care is
provided.

Facts About Your Home Care Services and Payment

This form explains the services the patient will receive during the episode of care including the
frequency and duration and the patient’s share of cost, if any.
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