Free Rights of Home Health Agency Patients-F-62601 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62601 (Rev. 04/09)

STATE OF WISCONSIN Page 1 of 2

RIGHTS OF HOME HEALTH AGENCY PATIENTS
Patients of a licensed home health agency (HHA) have the right to be informed of and to exercise rights specified in state regulations. Patients of an HHA that is also certified as a Medicare provider have additional rights under federal regulations. If a patient has been judged incompetent, the patient's family or guardian may exercise those rights on the patient's behalf. The following is an unofficial summary of rights provided by the state regulations [Section DHS 133.08(2), Wis. Admin. Code], and federal regulations (42 CFR 484.10), in effect in September 2004.

AS AN HHA PATIENT, YOU HAVE THE RIGHT · · · · · · · To be treated with consideration, respect, and full recognition of your dignity and individuality, including privacy in treatment and care for personal needs. To exercise your rights as a home health patient. 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 a. The extent to which payment may be expected from Medicare, Medicaid, or any other federally funded or aided program known to the HHA. b. The charges for services that will not be covered by Medicare. c. · 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 to 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 have your family or legal representative exercise your patient's rights when you have been judged incompetent by a court of law. 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 be informed of all regulations governing your responsibilities as a patient.

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F-62601 (Rev. 04/09)

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COMPLAINTS
1. 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. 2. You may also make complaints about your treatment or care directly to the HHA by calling or writing to the HHA administrator. 3. You may also make complaints by writing to Division of Quality Assurance Bureau of Health Services P. O. Box 2969 Madison, WI 53701-2969 4. If you have Medicare coverage, you may also make complaints by writing to Metastar 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. HHAs and HHA patients should rely on the official and current regulations for specific legal information in the event of a concern about patient rights. The official state and federal regulations may be accessed at

http://dhs.wisconsin.gov/rl_DSL/HHAs/HHAregs.htm

Patient or Representative signature is OPTIONAL. SIGNATURE ­ Patient or Representative Date Signed