Page 78 - Rehab 2020

Health Information Exchange Authorization Consent Form

This form is to authorize VNSNY to share the patient’s health information with authorized licensed
healthcare providers (e.g. doctors, emergency room departments, DME vendors, etc) through
Health Information Exchanges (HIE). HIEs ensure secure access and speed of delivery of
information when other healthcare providers need it.

The form:

* Explains what the Health Information Exchange is.

* Explains which health care providers will share information.

* Explains why a patient would want to share their health information.

* Informs patient of their rights in the Health Information Exchange.

* Informs patient who to contact for more information.

Emergency Preparedness Plan
This form contains information on how to prepare for an emergency. This includes how to create an
emergency supply kit, an emergency “go bag”, and emergency contact numbers. The clinician needs
to assist patient/ caregiver or patient representative in completing the checklist of emergency
numbers and medical supplies.
Mutual Care Agreement (if applicable)

A mutual care agreement is a form signed by the family or caregiver acknowledging their
participation in the patient’s plan of care and ensuring that the patient’s essential needs are met in an
emergency situation or the absence of agency personnel.

If there is a question as to the need of a mutual care agreement the following questions should be
considered:
a. Can the patient self-direct their care?

b. Can the patient summon help?

c. Can the patient be left alone safely?

If the answer to any of the above questions is no, then a mutual care agreement is needed
acknowledging the plan developed with the family/guardian for the patient’s safety and care at
home.

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