RESPITE APPLICATION - Access Services · 2019. 3. 28. · any infestations (past, present, or future), including, but not limited to: lice, fleas, bed bugs, happening within my home.

RESPITE APPLICATION

DATE:

Consumer Name:

DOB: Gender: Height: ______ Weight:

MA#:

SS#:

County Assigned#: _________________________________

Religious Preference: __________________________________________________

Ethnicity: ________________________________________

Parent/Guardian (if applicable):

Street Address:

City/State/Zip: __________________________

Township: _______________________________

Email Address: _______________________________

County: _______________________________

Home Phone #: _______________________________

Cell Phone #: _______________________________

School/Day Program/Club House/Employer:

Contact Person:

Phone #:

CURRENT SUPPORT CONTACTS

SUPPORTS UTILIZED

NAME OF AGENCY & CONTACT NAME

EMAIL ADDRESS

PHONE NUMBER

ON-CALL #

Case Manager/ Supports Coordinator

Family Based Services/ BHRS/ACT/CCT

Primary Care Physician

Psychiatrist/ Specialist

Outpatient/ Medication

Management

OTHER (OCY, Probation, Parole, etc.)

Lehigh Valley Office 3975 Township Line Road Bethlehem, PA 18020 Phone: 610-866-6667 Fax: 610-866-2341

ACCESS SERVICES, INC. Delaware Valley – Main Office

500 Office Center Drive, Suite 100 Fort Washington, PA 19034

Phone: 215-540-2150 Fax: 215-540-2165

www.accessservices.org

Schuylkill-Carbon Office

340 S. Liberty Street Orwigsburg, PA 17961 Phone: 570-366-1154

Fax: 570-366-7711

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EMERGENCY & PERSONAL CONTACTS (family and friends)

Name Relationship Phone Number

ADDITIONAL INFORMATION

Likes & Strengths Dislikes & Weaknesses

Summary of current living situation:

Summary of how respite will help:

SKILL LEVELS This section is for 16 years+ Respite Referrals

Budgeting for self: Can they manage their own money? Household skills: Would person like to cook for themselves?

Social skills: Does this person have friends? Experience in managing conflicts in relationships.

Problem solving: Does this person need support with decision-making?

Personal care and hygiene: What is this person’s bathing/hygiene routine? Do they need physical assistance or support getting around?

Wellness care: Does this person need reminders in taking medication? Have they ever made their own crisis or have a recovery plan?

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MEDICAL & PSYCHIATRIC INFORMATION

Medications must be sent with the individual in the original pharmacy bottle. No over-the-counter PRN medication can be administered unless it is included on this list. No PRN medication for behavioral control can be administered under Access Services Policy.

Medication Dose Frequency Reason

Current Medical Conditions (asthma, seizures, etc.) Medical History

Dietary Restrictions or Food Allergies Environmental Restrictions & Allergies

Current Mental Health Diagnosis Current Interventions

DESCRIPTION/HISTORY OF BEHAVIORS

History of violence or aggression (physical, verbal,

property destruction, etc.)

History of trauma/sexualized behaviors

History of suicidal thoughts or actions

OTHER (e.g., history of hospitalizations or 302, drug or alcohol use, hyperactivity, etc.)

PERMISSION FORMS & OTHER RELEASES

I understand, agree, and give permission for for the following: Name of Individual

EMERGENCY HOSPITAL TREATMENT To receive emergency medical/dental treatment to be given if necessary. I understand that I will be notified of any emergency by the Respite Coordinator as soon as possible.

TRAVEL PERMISSION

Initials

To be transported by Access Services Staff and Respite Family. Transportation will be for emergency, activity, and respite related circumstances.

RELEASE FOR RECREATIONAL ACTIVITY

Initials

To participate in recreational/sporting activities while in respite care with Access Services. Recreational activities may include but are not limited to: bike riding, horseback riding, rollerblading, and playing organized sports. I release and hold harmless, Access Services and the host family provider, from any liability for injuries that may result during the course of any recreational activity.

OUT OF STATE ACTIVITY

Initials

To be transported beyond the Pennsylvania state line in order that he/she accompany respite provider on a trip/vacation to another state. I give my full permission for this to occur. Any travel plans will be discussed with me prior to the respite occurring.

SIBLING CARE ACKNOWLEDGMENT

Initials

The Respite Provider may not provide care or oversight to any sibling or other child at the same time that the Respite Provider is providing Services to the child referred and approved through Access Services.

CANCELLATION POLICY Initials

I understand that once respite is scheduled I should provide 48 hours’ notice of cancellation. Failure to cancel with adequate notice may cause me to be financially responsible for the cost of respite.

Initials

Signature of Individual (14 years and up) Date

Signature of Parent/Guardian (if applicable) Date

Signature of Witness Date 4

PERMISSION FORMS & OTHER RELEASES

INFECTIOUS DISEASE POLICY In signing this policy I understand that it is my responsibility, and agree to notify Access Services, Inc. of any household members or current approved individual that currently suffers from a contagious disease.

INFESTATION POLICY Initials ___

I understand that in signing this I understand it is my responsibility, and agree to notify Access Services of any infestations (past, present, or future), including, but not limited to: lice, fleas, bed bugs, happening within my home. Access Services Inc. may require documentation from an exterminator that your home has been cleared.

Initials ___

VERIFICATION OF CUSTODIAL RIGHTS Please check the box next to the statement that best describes your situation and sign below.

In signing below, I verify that I have sole legal custody, and as such can make decisions regarding the treatment and care received. I can provide a copy of a custody order or other legal verification to support this claim.

In signing below, I have joint/shared legal custody, with another individual who does not live in my home. Access Services has my full permission to reach out to the guardian to receive the expressed consent of the other legal guardian

In signing below, I verify that the identified individual lives in the home with biological parents or adoptive parents.

In signing below, I verify that none of the scenarios above relate to my current situation and will explain further. I can provide a copy of a custody order or other legal verification to support this claim. (Explain):

Signature of Individual (14 years and up) Date

Signature of Parent/Guardian (if applicable) Date

Signature of Witness Date

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ACCESS SERVICES, INC. HIPAA – Summary of our Notice of Privacy Practices

Our Privacy Policy – This briefly summarizes how your personal health information is protected and how it is used. The full description of how we use and protect your health information is contained in our Notice of Privacy Practices. The notice explains your rights to inspect, copy, and amend your medical information. It also outlines your rights to restrict or limit how we use and share your health information.

We strongly encourage you to read our Notice of Privacy Practices and ask questions if you don’t understand. It is important for you to understand how your health information may be used and what your rights are regarding your health information.

You will be asked to acknowledge that you have received our Notice of Privacy Practices.

How We Use Your Health Information – Our Notice more fully explains how we use your health care information. For example, we may use your health information to plan and provide your care and treatment; communicate with health care professionals; obtain payment for our services; educate and train our staff; and assess and improve our services. We are also permitted to use and disclose your health information if required by law.

We may use your information to remind you about appointments and to let you know about other healthcare services that may be of interest to you. Please be assured that as much as possible, we will limit both the amount of information and the number of people with whom it is shared. Unauthorized disclosures of your information are strictly prohibited and are punishable by law.

Releases You Must Authorize – If the need arises to use or share your information for purposes other than treatment, payment and healthcare operations as described in our Notice of Privacy Practices, you will be asked to sign a separate authorization form. This form would describe what information would be disclosed, to whom, for what purpose, and when. You have the right to revoke or revise any authorization you sign at any time with the understanding that the change will not affect any uses or disclosures of your information that were made based on your prior authorization.

Special Requests – You may request a restriction, or limitation, on the medical information we use or disclose about you. For instance, you may request in writing that we not share your medical information with a particular family member or you may request in writing that we contact you only at work. In addition you may inspect your medical records at any time with advance notice. If you feel that the information on file for you is incorrect or incomplete, you may ask us to amend the information. Special requests must be made in writing.

Complaints – If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer or the Secretary of the U.S. Dept. of Health and Human Services. Complaints will in no way affect the quality of the care you receive.

For more information, please contact our Privacy Officer at 215-540-2150.

Please sign below to acknowledge receipt of our Notice of Privacy Practices.

Individual or Personal Representative’s Signature Printed Name Date

If signed by a personal representative, please indicate name of person for whom it is signed:

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500 Office Center Drive Suite 100

Fort Washington, PA 19034 215-540-2150 phone

215-540-2164 fax

Consent for Release of Information

Individual Name: DOB:

Name of Person Giving Consent: Relationship:

I agree to allow Access Services – Respite Program team to communicate with:

Name: Relationship:

Address:

so that I can get the best service possible (continuity of care). The information that will be shared is limited to:

Medical Information

Treatment Information

Other:

This agreement will begin today ____ / ____ / ____ and will expire on ____ / ____ / ____. (No longer than one year)

I understand that I can change my mind at any time and that I can revoke this permission to release my

information.

Date

My Name (Print) Witness (Print Name)

My Name (Signature) Witness (Signature)

Verbal permission provided: Date

Witness #1 (Print Name) Witness #2 (Print Name)

Witness #1 (Signature) Witness #2 (Signature)

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Respite Department – Physician’s Statement

This is to certify that , to the best of my knowledge, is free of communicable diseases. Nor does he/she have any medical condition which would interfere with his/her ability to function normally in regards to everyday activities.

** Physician Initials

Please comment with medical conditions or concerns we should be aware of:

Physician’s Name (printed):

Address:

City/State/Zip:

Physician’s Signature:

Date:

Lehigh Valley Office 3975 Township Line Road Bethlehem, PA 18020 Phone: 610-866-6667 Fax: 610-866-2341

ACCESS SERVICES, INC. Delaware Valley – Main Office

500 Office Center Drive, Suite 100 Fort Washington, PA 19034

Phone: 215-540-2150 Fax: 215-540-2165

www.accessservices.org

Schuylkill-Carbon Office

340 S. Liberty Street Orwigsburg, PA 17961 Phone: 570-366-1154

Fax: 570-366-7711