Home Care Request Policy

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By electronically completing and submitting the Home Care Request Form, I acknowledge and understand that I am submitting a request for Changing Seasons Healthcare to evaluate the individual identified in the form for potential in-home care, home health, personal care, supportive care, or other services that may be appropriate to the individual's needs.

I understand that submitting this form is a request for evaluation and consideration only. Submission of the form does not guarantee acceptance, eligibility, authorization, availability, scheduling, admission, or commencement of services.

I understand that Changing Seasons Healthcare may contact me or the individual identified in the form to obtain additional information and, when appropriate, conduct an initial or in-home assessment. The assessment may be used to determine the individual's care needs, service requirements, eligibility, safety considerations, and whether Changing Seasons Healthcare is able and appropriately licensed, authorized, and staffed to provide the requested services.

I understand that the determination to provide services may depend upon the individual's assessed needs, applicable program or payer requirements, physician or other healthcare provider orders when required, availability of appropriate services and personnel, and applicable federal and North Carolina laws, regulations, and professional standards.

By submitting this form electronically, I consent to and authorize Changing Seasons Healthcare and its authorized workforce members, representatives, contractors, and service personnel, as applicable, to collect, receive, review, document, maintain, and use the Personally Identifiable Information (PII) and Protected Health Information (PHI) that I voluntarily provide or that is reasonably necessary to evaluate, coordinate, and administer the requested services.

The information may include, as applicable, identifying information, contact information, medical history, diagnoses, medications, functional limitations, care needs, insurance information, and other information reasonably necessary to evaluate and coordinate services.

The information may be used or disclosed, as permitted or required by applicable law, for purposes including:

• Evaluating the individual's care needs and determining whether requested services may be appropriate;
• Conducting, documenting, and reviewing an initial or in-home assessment;
• Communicating with the individual, parent, legal guardian, caregiver, family member, or other authorized representative;
• Coordinating potential home care, home health, personal care, supportive care, or related services;
• Developing, implementing, reviewing, or modifying a plan of care when services are initiated;
• Coordinating care with physicians, nurses, therapists, facilities, hospitals, pharmacies, insurance companies, Medicaid or other payers, and other healthcare providers or authorized parties, when permitted or required by law;
• Obtaining or verifying information necessary for eligibility, coverage, authorization, billing, payment, or reimbursement;
• Supporting quality assurance, care coordination, compliance, recordkeeping, and healthcare operations; and
• Fulfilling applicable federal, state, payer, licensing, regulatory, legal, and documentation requirements.

Changing Seasons Healthcare will protect applicable PHI in accordance with HIPAA and other applicable federal and North Carolina privacy, confidentiality, and information-security requirements. Information will be accessed, used, or disclosed only as permitted or required by applicable law and, when applicable, pursuant to the appropriate authorization or other legal basis.

I understand that I should provide information concerning another individual only when I have the legal authority or appropriate authorization to provide that information and to request services on that individual's behalf.

If I am submitting this form as a parent, legal guardian, healthcare representative, personal representative, caregiver, or other authorized individual, I represent that I have the authority to make the request and provide the information necessary for the evaluation and coordination of requested services.

Changing Seasons Healthcare may request documentation or additional information when necessary to verify an individual's identity, representative authority, eligibility, or ability to consent to services.

I understand that submitting this form electronically constitutes my acknowledgment that the information I have provided is accurate and complete to the best of my knowledge.

I understand that my electronic submission, together with any required electronic acknowledgment or consent, may constitute my electronic signature, consent, or authorization to the extent permitted by applicable law.

I understand that Changing Seasons Healthcare may contact me using the contact information provided on this form regarding my request, the evaluation process, required documentation, scheduling, eligibility, care coordination, or other matters related to the requested services.

I understand that I may be asked to provide additional documentation, sign additional consent or authorization forms, participate in an assessment, or provide other information before services can be initiated.

I understand that submission of this form does not:

• Guarantee that Changing Seasons Healthcare will accept the individual for services;
• Guarantee that the individual is eligible for any particular service or payer program;
• Guarantee that services will be available at the requested time, location, or frequency;
• Guarantee insurance or Medicaid authorization or payment;
• Establish a continuing provider-patient or provider-client relationship; or
• Authorize treatment or services beyond those separately assessed, ordered, authorized, agreed upon, and provided by Changing Seasons Healthcare.

I understand that services, when approved and initiated, will be provided according to the applicable plan of care, professional requirements, payer requirements, and applicable laws and regulations.

I understand that the Home Care Request Form is not an emergency-response service and should not be used to report or obtain assistance for a medical emergency, psychiatric or behavioral health emergency, life-threatening condition, or immediate safety concern. If the individual is experiencing a medical or behavioral health emergency, is in immediate danger, or requires immediate medical attention, I understand that I should call 911 or seek emergency medical assistance immediately.

Submission of this form does not request, initiate, or guarantee emergency medical treatment or emergency response by Changing Seasons Healthcare.

By electronically submitting the Home Care Request Form, I confirm that:

1. I have read and understand this Acknowledgment, Consent, and Authorization;
2. The information I have provided is accurate and complete to the best of my knowledge;
3. I understand that Changing Seasons Healthcare may contact me regarding my request;
4. I consent to the collection, review, use, and disclosure of information as described above for the lawful purposes of evaluating and coordinating requested services;
5. I understand that additional information, documentation, assessments, consents, authorizations, orders, or agreements may be required before services can begin;
6. I understand that submission of this form does not guarantee acceptance, eligibility, availability, authorization, payment, or commencement of services; and
7. I understand that this form does not constitute an emergency medical request or authorize emergency medical treatment.

By submitting this form electronically, I affirm that I have read, understood, and agree to the terms stated above and authorize Changing Seasons Healthcare to proceed with the initial evaluation and service-request process.