Free Home Health Agency Patient Rights Statement Review-F-62646 - Wisconsin


File Size: 23.0 kB
Pages: 1
Date: April 27, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 668 Words, 3,991 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f6/f62646.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62646 (Rev. 04/09)

STATE OF WISCONSIN

HOME HEALTH AGENCY (HHA) PATIENT RIGHTS STATEMENT REVIEW
Name ­ Agency Name ­ Surveyor(s) License Number Review Date

YES

NO

PATIENT RIGHTS STATEMENTS [DHS 133.08(1) and (2), Wis. Admin. Code, and 42CFR 484.10] To exercise your rights as a home health patient. To be treated with consideration, respect, and with full recognition of your dignity and individuality, including privacy in treatment and care for personal needs. To have your property treated with respect. To confidential treatment of your personal and medical records and to approve or refuse their release to any individual outside the agency, except in the case of transfer to another health facility or as required by law or third party contract. To access your records upon request in accordance with the HHA's policy. To be informed in advance about the services available and the disciplines, frequency, and care to be furnished, as well as any changes in care or services to be furnished, before the changes occur. To be informed, orally and in writing, before care is initiated, of the following: · · · The extent to which payment may be expected from Medicare, Medicaid, or any other federally funded or aided program known to the HHA. The charges for services that will not be covered by Medicare. The charges for services for which you or a private insurer may be responsible.

In addition, to be informed orally and in writing of any changes in care regarding the payment sources and charges noted above when they occur. The HHA must advise you as soon as possible, but no later than 30 calendar days from the date that the HHA becomes aware of a change. To be fully informed of your health condition, unless medically contraindicated, and to be afforded the opportunity to participate in the planning of the home health services, including referral to health care institutions or other agencies, and to refuse to participate in experimental research. To be taught, and have your family taught, the treatments you need so that, to the extent possible, you can help yourself and have your family or others designated by you understand and help you. To voice grievances regarding treatment or care that is furnished or fails to be furnished or regarding lack of respect for your property by anyone who is furnishing services on behalf of the HHA. The HHA must not subject you to discrimination or reprisal for voicing a grievance or complaining about your treatment or care. To make decisions regarding medical care, including to accept or refuse treatment to the extent permitted by law, to be informed of the medical consequences of refusing care, and to formulate advance directives. To have your family or legal representative exercise your rights when you have been judged incompetent by a court of law. To be informed of all regulations governing your responsibilities as a patient.
YES NO

COMPLAINTS [DHS 133.08(3), Wis. Admin. Code, and 42 CFR 484.10] You may make complaints about your treatment or care, including how the HHA implements any advance directive that you make, by calling Wisconsin's Home Health Hotline at 1-800-642-6552, 24 hours a day, seven days a week. You may also make complaints about your treatment or care directly to the HHA by calling or writing to the HHA administrator. You may also make complaints by writing to the Division of Quality Assurance / Bureau of Health Services / 1 West Wilson Street, Room 1150 / PO Box 2969 / Madison, WI 53701-2969. If you have Medicare coverage, you may also make complaints by writing to Metastar at 2909 Landmark Place, Madison, WI 53713, or by calling Metastar at 1-800-362-2320. The HHA must investigate complaints that you or your family or your guardian make regarding your treatment and respect for your rights by anyone furnishing services on behalf of the HHA. The HHA must document such complaints and how they are resolved.