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    Admission Agreement Form Preview

    Printer-friendly PDF version of the Coming Home Hospice Admission Agreement Form
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    You will be asked to provide the following information and your consent on the Coming Home Hospice Admission Agreement Form.

    • Applicant's Name and Social Security number

    • I, the above named individual, request admission to Coming Home Hospice checked below and I acknowledge, consent, and agree to the following:
      I, the DPOA and/or the member of the immediate family for the above named applicant, request his/her admission to Coming Home Hospice checked below and agree to the following:

    Agreement Checklist

    1. As the resident, I ask that my family/friends respect my choice for palliative care at Coming Home Hospice.

    2. I understand that the care provided at Coming Home Hospice (CHH) is palliative, not curative, in its goals and techniques; that the program emphasizes the alleviation of physical symptoms, including pain, and the identification and meeting of emotional and spiritual needs which I, the resident and my family/friends may experience related to my illness.

    3. I understand that medical and professional nursing services are provided by Sutter Care at Home or other Hospice agency in consultation with my physician. These services include 24-hour home care aides, medical social workers, regular visits made by registered nurses and 24-hour on-call nurses and physician for emergencies. I understand that admission to Coming Home Hospice is dependent upon admission to certified hospice services.

    4. I understand that if my need for medical or nursing care should at any time exceed those services able to be provided by CHH staff or through the certified hospice agency, or if my condition should stabilize to the point where hospice services are no longer appropriate, I will be discharged from
      Coming Home Hospice and transferred to home or another appropriate facility.

    5. I understand that conditions for discharge from CHH could include:
      • a psychiatric emergency
      • failure of progression of illness, and
      • behavioral management issues.
    6. I understand that should I need 24 hour one-to-one supervision, I will need to provide a sitter or have this service provided by a family member.

    7. I give consent and approval for notation to be made both on the records of Coming Home Hospice and the certified hospice service regarding the care provided at Coming Home Hospice.

    8. I give consent and approval for the release of information and appropriate medical records to or from any health care provider or organization involved with my care.

    9. I understand that I am required prior to admission to be screened by my physician for pulmonary tuberculosis (TB). This is in compliance with recommendations of the San Francisco City & County Department of Public Health. I understand that if the screening should show me to have active TB, I must start on effective medical treatment prior to admission and continue that treatment during my stay.

    10. I understand that I am requested, prior to admission to Coming Home Hospice, to have and submit a copy of a Durable Power of Attorney for Health Care and a Durable Power of Attorney for Finances.

    11. Coming Home Hospice has a double-fee structure.
      • All residents will be charged a fee payable to Coming Home Hospice, which includes rent, meals and certain support services. I understand that it is my responsibility, or that of my designated responsible other, to make payments every month, using my funds, and that failure to make such payments may result in discharge from Coming Home Hospice. Generally, third party payer sources do not reimburse for the above charges.

      • Medical services provided by the Sutter Care at Home or other certified hospice service and costs for medications and equipment and other services will be charged to my third party payer sources or will be billed separately to me. I understand that I am responsible to pay for that portion of the bill that my third-party payer source does not pay.
    12. I understand that Coming Home Hospice may include both private and semi-private rooms and that assignment will be based on need and availability. I agree to being assigned or transferred to other rooms as necessary. Fees are the same for private and semi-private rooms.

    13. I understand that smoking is not permitted inside Coming Home Hospice. Outside areas are provided for this purpose.

    14. I understand that I may drink alcohol in moderation as directed by my physician and that abuse of alcohol or disruptive behavior may result in discharge from Coming Home Hospice.

    15. I understand that I am not permitted to keep or use weapons and/or illegal drugs of any kind at Coming Home Hospice.

    16. I understand that visitors may be limited at any time at my request, and that visitors will be asked to leave at any time if they become disruptive and/or disturb other residents.

    17. I understand that I may voice my concerns regarding the care provided at Coming Home Hospice in writing to the Manager of Coming Home Hospice and/or the Director of the hospice.

    18. I understand that my home address will become the address of Coming Home Hospice in which I live. I hereby authorize services to be provided to me at CHH and accept full responsibility for payment of such services.

    My signature acknowledges that I understand all of the above and that I have been given ample opportunity to ask any and all questions concerning Coming Home Hospice, the care provided, related charges, and complaint procedures.

    Applicant or DPOA/Immediate Family Member

    • Signature

    • Print Name

    • Relationship

    • Date