Patient Intake and Consent Form Contact Us! Thank you {{patient_name_}} for submitting your Patient Intake and Consent Form information to HomeMD Health.We will contact you within 1 business day. Notice of ACO Participation Medicare Shared Savings Program ACO 11https://www.homemdhealth.com/wp-content/plugins/nex-formstruehttps://bestbuy.commessagehttps://www.homemdhealth.com/wp-admin/admin-ajax.phphttps://www.homemdhealth.com/patient-intake-and-consent-formyes1fadeInfadeOut Patient Intake and Consent FormPlease complete our online Patient Demographic Form to register yourself or your loved one for service with HomeMD Housecall Services. Once we receive your intake information along with the signed consent form, a referral specialist will contact you shortly thereafter (usually the same day) to coordinate for the first appointment with our provider staff.Referral By :Patient Name *Patient Date Of Birth *Email Primary Phone Primary Phone Type: Home Phone Cell Phone Secondary Phone Secondary Phone Type: Home Phone Cell Phone Best time to call 8AM - 11AM11AM - 1PM1PM - 3PM3PM - 5PMBest way to contact you By Phone By EmailSSN or Medicare Card #*Gender: Male Female Marital Status: Single Married Divorced SeparatedPatients Address*Street Address Apt. or Suite*City *State*Zip Code Billing Address (if different than patients primary address) Street Address Apt. or SuiteCity StateZip Code *Patient lives in a . . . Residential House Assisted Living Facility Independent Living Facility Memory Care Unit Group HomeFacility Panel AreaName Of FacilityPrimary Insurance Information :Primary Plan Type Traditional Medicare Priority Health HAP (Health Alliance Plan) Humana Wellcare Molina Meridian PHP (Physicians health plan) Mclaren Health Plan Michigan Medicaid Other Other Primary Insurance Plan typePrimary Member ID # *Primary Group # Secondary Insurance Information :Secondary Plan Type Traditional Medicare Priority Health HAP (Health Alliance Plan) Humana Wellcare Molina Meridian PHP (Physicians health plan) Mclaren Health Plan Michigan Medicaid Other Other Secondary Insurance Plan typeSecondary Member ID #Secondary Group #Plan ( of Secondary Insurance )Submit Image of Insurance Card ( front )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Submit Image of Insurance Card ( back )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Submit Image of State ID / Driver License ( front )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Submit Image of State ID / Driver License ( back )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Emergency ContactRelationship to the Patient * Self Guardian DPOA Health Care Advocate Relative OtherName of Emergency Contact Emergency Contact Cell Number Emergency Contact Home Number Emergency Contact Email Health Care Advocate / DPOA / GuardianMedical - DPOAFinancial - DPOAGuardiansHealth Care AdvocateOtherMedical - DPOAMedical - DPOAUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Financial - DPOAFinancial - DPOAUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf GuardiansGuardianUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Health Care AdvocateHealth Care AdvocateUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf OtherOtherUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Primary Care Information( So that we can coordinate care and/or retrieve records, if we are assuming primary care )Current or Former PCPs NameCurrent or Former PCPs Phone #Current or Former PCPs Fax #YesPlease have HomeMD Housecall Services assume housecall based primary care for myself or my loved oneYesPlease have HomeMD Housecall Services provide me with information about in-home primary careYesPlease set me up with a remote monitoring service so my vital sign readings can be reviewed in real-time by my providerPreferred Remote monitoring ServiceBP CuffGlucometerWeight ScalePatient HistoryMedical HistorySurgical HistoryPreventive Care HistoryHealth and Safety Questions1. How often do you have trouble handling stressful things such as your health, finances, or work relationships?AlwaysSometimes Never2. How often do you get the social and emotional support you need?AlwaysSometimes Never3. In general, how satisfied are you with your life?Very Satisfied/Very Happy Satisfied/HappyUnsatisfied/Unhappy Unsatisfied/Very Unhappy4. Do you struggle to hear the TV or radio, or struggle to understand conversations?AlwaysSometimes Never5. Do you need help with preparing meals, transportation, shopping, taking your medicine, or managing your finances?AlwaysSometimes Never6. Do you need help eating, getting dressed, grooming, bathing, and/or using the toilet?AlwaysSometimes Never7. Do you have a working smoke alarm in your home?YesNo8. Does your home have loose rugs in the hallway?YesNo9. Does your home have poor lighting?YesNo10. Does your home have grab bars in the bathroom?YesNo11. Does your home have handrails on the stairs?YesNo12. Do you live alone?YesNo13. Do you always fasten your seat belt when you are in the car?AlwaysSometimes Never14. In the past 7 days, on how many days did you drink alcohol?None1-2 days 3-4 days Daily15. How many of those days did you have four or more drinks?None1-2 days 3-4 days Daily16. Do you ever drive after drinking or ride with a driver who has been drinking?AlwaysSometimes Never17. How many days a week do you usually exercise?None1-2 days 3-4 days Daily18. How intense is your typical exercise?NoneLight (slow walking)Moderate (brisk walking, using light weights, swimming)Heavy (running, using heavy weights)19. On a typical day, how many servings of high fiber or whole grain foods do you eat? (1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole grain or high fiber ready-to-eat cereal, 1⁄2 cup of cooked cereal such as oatmeal, 1⁄2 cup of cooked brown rice or whole wheat pasta)None1-2 servings3-4 servings20. On a typical day, how many servings of fruits and/or vegetables do you eat? (1 serving=1 cup of fresh vegetables, 1/2 cup of cooked vegetables, or 1 medium piece of fruit.)None1-2 servings3-4 servings21. On a typical day, how many servings of fried or high-fat foods do you eat? (ex: fried chicken, fried fish, bacon, French Fries, potato chips, corn chips, doughnuts, creamy salad dressings, and foods made with whole milk, cream, cheese, or mayonnaise)None1-2 servings3-4 servings22. In the past 7 days, on a scale of 1 – 10, how much pain have you felt?None1-3 minimal pain4-6 moderate pain7-8 severe pain9-10 uncontrollable pain Location:_____________23. How many hours of sleep do you usually get each night?0-1 hours2-4 hours5-6 hours8 hours+Nap dailyHave difficult time falling asleep24. Who are your current medical suppliers? (Example: durable medical equipment, oxygen supplier, etc.) Name and Phone Number:25. Who are the doctors you see? (Example: heart specialists, lung specialists, etc) Name and Phone Number:Please list all medications ( include dosage strength and frequency )Upload Digital Medication List *(Optional)Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Pharmacy NamePharmacy Phone Number2ND Pharmacy Name2ND Pharmacy Phone NumberOther Pertinent Information or NotesPlease choose a service, and then scroll down to see the service description below.*Requested ServicesPrimary CarePalliative CareWound CarePodiatry CareBehavioral Heath / PsychCounseling Services (licensed medical social worker)Remote Monitoring ServicesPrimary Care Services DescriptionPrimary Care ServicesPrimary care in the home carried out by experienced nurse practitioners who have beenworking with homebound clients including geriatrics and their families for many years. Our providers are very much tuned in to the frustrations that geriatric clients and their families run into when trying to navigate a very complicated and fragmented medical care system. Diagnostics including labwork and imaging services are provided in the comfort of your livingroom, reducing the need for back and forth >trips to the PCP, which often require family members to take days off work. Our primary care program was designed to empower patients and their families with access to a level of comprehensive care that can’t be found anywhere else while accomplishing it all in one place, your living room.Palliative Care Services DescriptionPalliative Care ServicesPalliative Care ‐ Runs as a supplement to outside primary care for individuals who require frequent symptom management and/or for patients who need frequent, oftentimes unpredictable “check‐in’s” to put out fires secondary to chronic conditions; clients may keep their current primary care provider whom our clinical team will then coordinate care with.Wound Care Services DescriptionINFORMED CONSENT FOR WOUND CARE TREATMENT*Patient NameHow many wounds does the patient currently have?How old is the patient’s wound(s)?Date Of BirthWhat type(s) of wound(s) does the patient have?Where are the patient’s wound(s) located?Patient hereby voluntarily consents to Wound Care Treatment by HomeMD Housecall Services and their respective staff. Patient understands that this consent form will be valid and remain in effect as long as the patient remains active and receives services and treatments. A new consent form will be obtained when a patient is discharged and returns for services and treatments. Patient has the right to give or refuse consent to any proposed service or treatment. General Description of Wound Care Treatment: Patient acknowledges that their treatment for wound care has been explained to them and can include, but not be limited to: debridement’s, dressing changes, biopsies, skin grafts, off-loading devices, physical examinations and treatment, diagnostic procedures, laboratory work (such as wound care cultures), request x-rays, recommend hyperbaric oxygen therapy, other imaging studies and administration of medications prescribed by a physician. Patient acknowledges that the physician has given them the opportunity to ask any questions related to the services or treatments being provided and that all questions have been answered. Benefits of Wound Care Treatment: Patient acknowledges that they have been explained the benefits of wound care treatment, which include: enhanced wound healing and reduced risks of amputation and infection. Risks and Side Effects of Wound Care Treatment: Patient acknowledges that they have been explained that wound care treatment may cause side effects and risks including, but not limited to: infection, pain and inflammation, bleeding, allergic reaction to topical and injected local anesthetics or skin prep solutions, removal of healthy tissue, delayed healing or failure to heal, possible scarring and possible damage to: blood vessels, surrounding tissues, organs and nerves. Likelihood of achieving goals: Patient acknowledges that they have been explained by following the proposed treatment plan they are more than likely to have optimized treatment outcomes; however, any service or treatment carry the risk of unsuccessful results, complications and injuries, from both known and unforeseen causes. General Description of Wound Debridement: Patient acknowledges that they have been explained that wound debridement means the removal of unhealthy tissue from a wound to promote healing. During the course of treatment, multiple wound debridement’s may be necessary Risks/Side Effects of Wound Debridement: Patient acknowledges that they have been explained the risks and/or complications of wound debridement include, but are not limited to: potential scarring, possible damage to blood vessels or surrounding areas such as organs and nerves, allergic reactions to topical and injected local anesthetics or skin prep solutions, excessive bleeding, removal of healthy tissue, infection, ongoing pain and inflammation, and failure to heal. Patient specifically acknowledges that they have been explained that bleeding after debridement may cause rapid deterioration of an already compromised patient. Patient specifically acknowledges that they have been explained that drainage of an abscess or debridement of necrotic tissue may result in dissemination of bacteria and bacterial toxins into the bloodstream and thereby cause severe sepsis. Patient specifically acknowledges that they have been explained that debridement will make the wound larger due to removal of necrotic (dead) tissue from the margins of the wound. Patient Identification and Wound Images: Patient understands and consents that those images (digital, film, etc.) may be taken by HomeMD Housecall Services of the patient and all patient’s wounds with their surrounding anatomic features. The purpose of these images is to monitor the progress of wound treatment and ensure continuity of care. Patient further agrees that their referring physician or other treating physicians may receive communications, including these images, regarding patient’s treatment plan and results. The images are considered protected health information and will be handled in accordance with federal laws regarding the privacy, security and confidentiality of such information. Patient understands that HomeMD Housecall Services will retain ownership rights to these images, but the patient will be allowed access to view then or obtain copies according to state and Federal law. Patient understands that these images will be stored in a secure manner that will protect privacy and that they will be kept for the time period required by law. Patient waives any and all rights to royalties or other compensation for these images. Images that identify the patient will only be released and/or used outside HomeMD Housecall Services upon written authorization from the patient or patient’s legal representative. Use and Disclosure of Protected Health Information (PHI): Patient consents to HomeMD Housecall Services use of PHI, results of patient’s medical history and physical examination and wound images obtained during the course of patient’s wound care treatment and stored in the HomeMD Housecall Services wound database for purposes of education, research, quality assessment and improvement activities and development of proprietary clinical processes and healing algorithms. Patient’s PHI may be disclosed by HomeMD Housecall Services to its affiliated companies, and third parties who have executed a Business Associate Agreement. Disclosure of patient’s PHI shall be in compliance with the privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Patient specifically authorizes use and disclosure of patient’s PHI by HomeMD Housecall Services its affiliates, and business associates for purposes related to treatment, payment and health care operations. If patient wishes to request a restriction to how his/her PHI may be used or disclosed, patient may send a written request for restriction to HomeMD Housecall Services, 5758 Cooley Lake Road, Waterford, MI 48327. Financial Responsibility: Patient understands that regardless of his or her assigned insurance benefits, patient is responsible for any amount not covered by insurance. Patient authorizes medical information about patient to be released to any payor and their respective agent to determine benefits or the benefits payable for related services. The patient hereby acknowledges that he or she has read and agrees to the contents of sections 1 through 9 of this document. Patient agrees that his or her medical condition has been explained to him or her. Patient agrees that the risks, benefits and alternatives of all care, treatment and services that patient will undergo while a patient at HomeMD Housecall Services have been discussed with patient. Patient understands the nature of his or her medical condition, the risks, alternatives and benefits of treatment, and the consequences of failure to seek or delay treatment for any conditions. Patient has read this document, or had it read to him/her and understands the contents herein. The patient has had the opportunity to ask questions and has received answers to all of his or her questions. By signing below, patient consents to the care, treatment and services described in this document and orally, consents to the creation of images to record his or her wounds and consents to the transfer of health information protected by HIPAA. Explanation to the patient (or his or her legal representative), the nature of the treatment, reasonable alternatives, benefits, risks, side effects, likelihood of achieving patient’s goals, complications and consequences which are/or may be associated with the treatment or procedure(s) has been provided. *Patient Signature or Authorized RepresentativePlease flip your phone sideways when signing this form, For tablets, please refresh your browser to erase the signature. NO info will be lost.*Date Of SignaturePodiatry Care Services DescriptionPodiatry Care ServicesPodiatry Care – ankle, foot, and nail care in the homeBehavioral Heath Psych Care Services DescriptionBehavioral Heath / Psych Care ServicesNurse practitioners/medical providers who are able to make medication adjustments and order treatments centered around behavioral care services. Suitable for depression, isolation, anxiety, dementia, behaviors secondary to dementia, and abnormal psychology. Oftentimes complemented by our counseling services.Counseling Services licensed medical social worker DescriptionCounseling Services (licensed medical social worker)Services provided by licensed medical social workers in the home. Can also be provided telephonically through our tablet program.Remote Monitoring Services DescriptionRemote Monitoring ServicesCloud connected blood pressure cuffs, weight scales, and diabetic glucometers that report readings to our office. These devices monitor and report to our provider staff when vital sign readings indicate that there may be a problem. Oftentimes when our providers are alerted to vital signs that may be of concern, this may indicate a need for intervention, which our providers can take either onsite or telephonically.Ask us any questions or share details ...YesI HAVE READ OR HAVE HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAVE HAD THESE QUESTIONS ADDRESSED TO MY SATISFACTION.*Submitters Status :I am the ______________* Patient Guardian DPOA Health Care Advocate Relative Other *Patients or Advocates Signature of Consent Please flip your phone sideways when signing this form, For tablets, please refresh your browser to erase the signature. NO info will be lost.Type in Your Name *Date of Consent : [wpdts item="date"]I have read and understand the privacy policy *Yes.I have read the and understand the Terms & Conditions*Yes.SUBMIT
