As the health care industry’s most comprehensive library of customizable policy and procedure templates, MCN Healthcare’s Home Infusion Therapy Policy and Procedure Manual includes this customizable template, Consent for Home Care Services/Assignment of Insurance Benefits Form. MCN’s policy library helps you meet compliance with Joint Commission and federal regulations including CMS, CDC, OSHA, OIG, HIPAA and more.

MCN provides more than 80 health care specific policy and procedure manuals for Acute Care Hospitals, Ambulatory Care, Behavioral Health, Home Health, Physician Practice, and Long Term Care. MCN’s policy and procedure manuals focus on the latest healthcare "hot topic" issues related to patient safety and prevention of medical healthcare errors.

Here is some sample content from Consent for Home Care Services/Assignment of Insurance Benefits Form:

	CONSENT FOR HOME CARE SERVICES/ ASSIGNMENT OF INSURANCE BENEFITS Request for Home Care Services I understand that by signing this agreement, I indicate my desire to purchase the following home care services and/or products from Agency: I understand that the possible complications and risks of acquiring these services in the home are similar to those in the hospital. I understand that emergency treatment is not available as quickly in the home as it is in the hospital. I have received information on handling any emergencies that might occur. I understand that specially trained nurses...
Second excerpt:
	...benefits payable to related services. In Medicare assigned cases, agrees to accept the charge determination of the Medicare carrier as the full charge and the client is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of Medicare. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance...