{"ref":"NC-HH-PR-03","title":"Service Agreement, Consent, Statement of Services and Charges, and Notice About Record Review","category":"Client rights","summary":"Requires a signed service agreement for every patient before care begins, recording the patient’s informed consent to the planned services, a written statement of the services and the charges the patient may have to pay (with oral explanation), the process for acceptance, continuance and eligibility, the right to refuse, consent to share information with other providers, and the patient’s right to be told in writing before the Division of Health Service Regulation reviews the record and to object.","inShort":["The patient signs the service agreement before the first visit of care.","Explain in plain words what services are planned, who will pay, and what the patient may owe.","If coverage or charges change, tell the patient before the next visit and give the new information in writing.","A patient can refuse any service. Respect it, explain the risks, write it down and tell the supervising nurse.","If the patient is not competent, the legal representative signs. Still explain the care to the patient."],"primaryCitation":"G.S. 131E-144.3","citations":["G.S. 131E-144.3","G.S. 131E-141","10A NCAC 13J .1402(a)","10A NCAC 13J .1111(a)","10A NCAC 13J .1202(a)","NC Medicaid Clinical Coverage Policy 3A"],"federalCitations":["42 CFR §484.50(c)(4)","42 CFR §484.50(c)(7)","42 CFR §484.50(c)(8)","42 CFR §411.408","42 CFR §405.1200","42 CFR §484.60(d)","45 CFR §164.506"],"surveyorAsks":["Show me this patient’s signed agreement. Did it come before the first visit of care?","How did you tell the patient, orally and in writing, what Medicare or Medicaid would pay and what he or she might owe?"],"forms":[{"ref":"NC-HH-PR-03-A","title":"Home Health Services Agreement and Consent"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (G.S. 131E-144.3(7), (9); 42 CFR §484.50(c)(4), (7))","5. Before Care Begins","6. What the Agreement Contains","7. Payment Information and Changes","8. Advance Written Notice of Non-Covered Care and of Reductions or Terminations","9. Consent, Refusal and Changes in the Plan of Care","10. Patients Who Are Not Competent","11. Sharing Information for Coordination of Care","12. Notice About Review of Records by the Department","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"nc-hha","state":"North Carolina","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}