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Client Application

    RACE

    MARITAL STATUS

    DO APPLICANT HAVE A POWER OF ATTORNEY?

    DO APPLICANT HAVE LIVING WILL OR ADVANCE DIRECTIVES?

    RESIDENCE TYPE

    IS THERE ANY HISTORY OF MENTAL ILLNESS OR DEVELOPMENTAL DISABILITY?

    IS THERE ANY EVIDENCE OF MEMORY LOSS?

    NEED FOR SERVICES: ACTIVITIES /INSTRUMENTAL OF DAILY LIVING

    PRIMARY ADL:

    INSTRUMENTAL ADL:

    ARE THERE ANY OTHER AGENCIES PROVIDING SERVICES?

    STATEMENT OF CLIENT RIGHTS:

    • the right to be treated with respect& dignity of his/her individuality& privacy.

    • to receive care& services which are adequate appropriate with relevant to federal and state laws, rules and regulation.

    • to be free of mental and physical abuse. Neglect& exploitation

    • the right to encouraged &supported in maintaing one's independence to the extent that conditions and circumstances permit

    • the right to self determination and being informed about services rendered & the opportunity to participate in developing one's plan of care

    • the right to be cared for in an atmosphere of sincere interest & concern in which needed support services are provided

    • the right to have personal & medical records kept confindental an not disclosed without written consentof the individual or guardian

    • the right to voice grievances about their care & not be subject to discrimination or reprisal for doing so

    • the right to be informed of their liability for payment services

    • the right to be informed of the process of acceptance & continuance of services & eligibility determination

    • the right to accept or refuse services

    • the right to be informed of the agency's on call service

    • the right to be informed of supervisory accessibility & availability.

    • the right to be advised of the agency's procedure for discharge

    COMPLAINTS, PLEASE CONTACT YOUR LOCAL DIRECTOR

    OFFICE: 301-925-8313
    FAX:301-925-0156
    EMAIL: Carmen@smartchoicehomecare.net

    STATECOMPLAINTS:WWW.dhmh.state.md.us/ohcq/faq or1800-492-6005

    I have read, understood and have a copy for my records of the agency's client rights & responsibilities.

    I HEREBY GIVE SMART CHOICE HOME CARE LLC AUTHORIZATION CONSENT TO RELEASE INFORMATION WITHIN MY CLIENT RECORD TO THE FOLLOWING:

    PHYSICIAN MEDICAL PROVIDER THIRD
    PARTY PAYER

    The release of information within my client record to the above-named parties may be used To provide me, the client, with proper healthcare treatment, for reference to other healthcare Providers, to obtain payment for services, collection departments, health plans and their Agents which may provide my coverage and agents or staff who review the care I receive to Prove that it and the cost associated are appropriate for my medical condition and /or Injuries. This authorization consent also may be used to share client record information with A family member, relative, friend or other persons I designate who are involved with my Medical care, and/or payment for the care I receive by smart choice home carellc. Futhermore, My client information can be shared for staffing the services required in the agency's Assignment process or to other public or private agencies for disaster relief and/or emergency Circumstances.

    I have read the terms of the application and have volunteered requested information