In-Home Care & Health Authorization

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Welcome to Changing Seasons Home Healthcare. We are honored to support your family through every season of life. To help us design the safest, most effective, and most compassionate care plan for you or your loved one, please complete the following service request.

Explicit Request for In-Home Treatment Services: 

By completing and submitting "Home Care Request Form" electronically, I am officially requesting in-home healthcare or daily living support services from Changing Seasons Healthcare. I acknowledge that my electronic submission of this Home Care Request Form authorizes Changing Seasons Healthcare to initiate and complete a thorough in-home assessment, and grants permission to collect, store, and utilize the Protected Health Information (PHI) requested in order to complete the care evaluation process:

• Skilled Medical Care: Nursing assessments, wound care, medication administration, and vital sign monitoring.
• Therapeutic Services: Physical, occupational, or speech therapy.
• Personal Care & ADLs: Assistance with activities of daily living, including bathing, dressing, mobility assistance, and meal preparation.
• Emergency Response: Implementation of safety protocols and emergency interventions as deemed medically necessary by the attending care team.

I understand that no medical treatments or skilled nursing interventions will be performed without the ongoing direction of a primary care physician and a mutually agreed-upon care plan.

Protected Health Information (PHI) & HIPAA Consent: To provide the highest standard of care, we need a clear picture of your current health. The following sections will ask you to input sensitive personal and medical data.

Authorization to Collect and Use PHI: By entering my data and submitting this form, I explicitly authorize Changing Seasons Home Healthcare to collect, store, and utilize my (or my loved one's) Protected Health Information (PHI).

I acknowledge that:

1. Purpose: This PHI will be used exclusively for evaluating medical needs, establishing a personalized treatment plan, ensuring patient safety in the home, and coordinating with my broader healthcare team.
2. Confidentiality: All provided information, including medical history, diagnoses, and financial details, will be safeguarded in strict compliance with the Health Insurance Portability and Accountability Act (HIPAA).
3. Authorized Sharing: I grant permission for Changing Seasons Home Healthcare to share this necessary PHI with my primary care physician, assigned caregivers, and relevant insurance or billing providers solely for the purposes of treatment coordination and payment.