Free Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a CBRF-F-62369 - Wisconsin


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State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
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http://dhs.wisconsin.gov/forms1/F6/F62369.pdf

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DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62369 (Rev. 04/09)

STATE OF WISCONSIN
Page 1 of 2

WAIVER OF HOSPICE OR HOME HEALTH SERVICES
BY A TERMINALLY ILL RESIDENT OF A COMMUNITY BASED RESIDENTIAL FACILITY (CBRF )
Completion of this form by the resident is voluntary per DHS 83.38(2)(b), Wis. Admin. Code.
Name Resident Date

Name CBRF

Telephone Number

Address

City

State

Zip Code

A terminally ill resident of a Community Based Residential Facility (CBRF) may waive the requirement that he or she receive the services of a Hospice Program or a Home Health Agency for his or her terminal illness while continuing to reside in the CBRF. It is important for the resident or his or her guardian or agent to make an informed decision on whether or not to waive services from these agencies. An agent of the resident can be the person designated in the power of attorney for health care document that has been activated. (This may include durable power of attorney documents that gave health care decision making powers to an agent.) Therefore, prior to waiving these services, the CBRF must ensure that the resident and his or her guardian or agent are provided with information about the type of services generally offered by a Hospice Program or Home Health Agency. The CBRF must provide an opportunity to: 1. Speak with a representative of a Hospice Program or Home Health Agency. 2. Review literature for a Hospice Program or Home Health Agency which describes its services to a terminally ill person. If the services of a Hospice Program or Home Health Agency are waived by the resident or his or her guardian or agent, the CBRF is required to coordinate all of the care and services for the terminally ill resident. The resident or the resident and his or her designated representative, or his or her guardian or activated health care agent may, at any time, revoke this waiver and receive services from a Hospice Program or Home Health Agency by signing the Revocation of Waiver on the second page of this form. Having been provided the opportunity to speak with a representative of a Hospice Program or Home Health Agency and review literature from at least one of these agencies, I hereby waive the services of a Hospice Program or Home Health Agency.
SIGNATURE - Resident (and designated representative, if previously requested by resident in writing)
Date Signed

OR

SIGNATURE - Guardian or Agent

Date Signed

F-62369 (Rev. 04/09)

Page 2 of 2

REVOCATION OF THE WAIVER OF HOSPICE OR HOME HEALTH SERVICES

I hereby revoke the waiver on the opposite side of this form so that I may receive the services of a Hospice Program or Home Health Agency.

SIGNATURE Resident (and designated representative, if previously requested by resident in writing)

Date Signed

OR

SIGNATURE - Guardian or Agency

Date Signed