Admission/Assignment of Benefits - 100/pack

Description

Designed to meet the Conditions of Participation for Medicare, this two-page, two-part carbonless form features necessary content to obtain patient and/or authorized representative consent for treatment.   The form details and documents a variety of home care admission related items including:   Primary Payer/Advance Directive Screening Consent for Treatment Release of Information Authorization and Liability for Payment Acknowledgment for Patient Receipt of Information regarding Notice of Services provided and Rate Sheet, HIPAA, Advance Directives, Emergency Planning, Patient Rights and more

Features

Convenient minimum order quantities of 100

Specifications

Size	8-1/2 x 11-5/8
Unit	Package of 100
Number of Pages	2
Other Info	Handwritten
Number of carbonless parts	2
Hole Punch	3 holes left

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