{"ref":"NC-HSP-PR-02","title":"Informed Consent, Service Information and Charges","category":"Client rights","summary":"Requires a written informed consent signed by the patient before hospice services begin (or by the guardian, health care agent or primary caregiver when the patient cannot sign), written information about services and how to reach on-call staff, and a written statement of services and charges, and sets out the admission packet and the patient's continuing right to accept or refuse services.","inShort":["The patient signs the informed consent (Form NC-HSP-PR-02-A) before the first service.","If the patient cannot sign, the guardian, health care agent or primary caregiver signs. Write down why.","The consent is not the Medicare election statement. Both are needed when Medicare or Medicaid pays.","Give the written service information, the on-call number and the statement of charges.","The patient may refuse any service at any time. Explain the effect, respect it and document it.","Never take photographs without written consent, and only on Agency devices."],"primaryCitation":"10A NCAC 13K .0601(4)","citations":["10A NCAC 13K .0102(14), (25)","10A NCAC 13K .0601(4), (6)","10A NCAC 13K .0901(a), (b)(9)","G.S. 131E-144.3(7), (8), (9)","G.S. 131E-207"],"federalCitations":["42 CFR §418.52(a), (c)(3), (7), (8)","42 CFR §418.24(b)(5)","42 CFR §418.400","42 CFR §418.100(d)"],"surveyorAsks":["Show me the signed informed consent for this patient. Was it signed before the first service?","This patient did not sign. Who signed, and where is the reason recorded?"],"forms":[{"ref":"NC-HSP-PR-02-A","title":"Hospice Informed Consent and Service Agreement"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13K .0601(4))","5. Who Signs the Informed Consent","6. The Admission Packet","7. Information About Services","8. Statement of Services and Charges","9. Continuing Consent and Refusal of Services","10. Other Consents","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"nc-hospice","state":"North Carolina","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}