Spans sh. BROADWAY RESPITE AND HOME CARE 24-20 Broadway Avenue Fair Lawn, NJ07410 Telephons: 207-703-380 Authorization for Services [Consent for Treatment. rauthorizs BROADWAY RESPITE AND HONE CARE andils employees to provide home oare services. | authorize healthcare personnel fo examine me in order to determine whether | am eligible fr the level of care offered by BROADWAY RESPITE AND HOME GARE. [Client Rights Statement have recoived and reviewed the Client Rights and Responsibilies statement and lacknowledge that [can refuse care oF services at any time. [Advance Directives -JAdvanice Directives are written inatiaolone to be caitiod out ia the evant you are Unable to make your own heslihéare decisions. ‘The [Agency does not roquito that you have an Advance Directive in oider to receive services. Howover, the Agency must provide you with |wrtten infornetion about Acvanco Directives. t acknowledge that have received writen information about Advance Directives from the Agency, I have a medal durable power df aliomey (DPOA) or Healthearé Name and pana aunbor of DFOR oF Heals Pry, Fappteabie. Proxy Yes No inthe event | stop breathing or my heart stops beating, | went to receive emergency sorvices. Yes_No if do not want To receive emergancy services, the Agarey wil halp me ablain a "bo Not Resuscitate" order from my Iphysiciah. | understand that Agency employees are legally obligated to contact emergency services unless | have sighed document from my physician. This order is neaded to protect me and the Agency. also give BROADWAY RESPITE AND HOME CARE permission to act on my behalf during medical emergencies until my guardian or designee arrives. [Scheduling of Services SFIOADWAY RESPITE AND HOWE CARE will make every effort to provide uninterrupted services and will notify mo or ny family, in timely manner, when unable to provide services. In the event tis situation arises, my back-up plan Is to: Transportation and Driving of Client by Caregivers BROADWAY RESPITE AND HOME CARE does not provide transportation services. IF client accopls transportation [services from the caregiver, these services are not authorized by the Agency. The Agency disclaims any lability oF nancial responsibilty to tho client for personal injuries or property damage caused by negligent conduct while driving with Ja BRHC caregiver. [Complaint Process: BROADWAY RESPITE AND HOME GARE staves fo provide effocive home care serves. In the event you have a complaint about your carogiver, cervices, billing, or scheduling, cantact the Executive Director at the phone numbor listed above. The Executive Diroctor wil contact you within 24 hours to datermine the nature ofthe problem and wil work with you to find a reesonable solution to tho problem. If you are not satisfied with the solution, the Executive Director and Agency Administrator will discuss the problem and Ithe Agency Administrator will contact you with a solution. Ifthe Agency is unable to resolve the problom to your satistaction, you have the right to discontinue services. Further, you may filo a complaint with the State of New Jersey, Division of Consumer Protection at 1- }201-504-6200. [Notice of Privacy Practices | acknowedge receipt of the HIPAA required Notice of Privacy Practices. You do not have fo acknowledge recelpt of the Notice of Privacy Practices. However, the BRHC employee must document that you were provided the information and would not sign. [Home Safety and Emergency Preparedness acknowledge receipt of Home Safety and Emergeney Preparedness Information [Client/Guardian's/DPOA Signature Date. Date IBRHC Employee's Signature {Must have Stat, With compan cl Joint Commission 2.Can wat 2 days fr Stat ‘on Acerredtaton, Office of Qualty ‘Hes alternate arrangements, telephono numbers of local Poe Opt ‘Mentoring at 1-800-894-0810