AGENCY’S NAME GOES HERE PATIENT CHOICE STATEMENT PATIENT NAME

(YOUR AGENCY’S NAME) REPRODUCTIVE HEALTH PROGRAM ADMINISTRATIVE POLICIES AND
8 PROPOSAL FOR ADDITIONAL GEF FUNDING (ADDON) AGENCY’S PROJECT
AGENCY’S NAME GOES HERE PATIENT CHOICE STATEMENT PATIENT NAME

AGENCY’S NAME INCIDENT HANDLING AND RESPONSE PLAN DATE LEDS
ASSESSING YOUR AGENCY’S COMMITMENT WORKSHEET 1 DETERMINE WHO
COMPANY’SAGENCY’S LETTERHEAD & FULL REGISTERED ADDRESS & BUSINESS REGISTRATION

Patient Choice Statement

AGENCY’S NAME GOES HERE


PATIENT CHOICE STATEMENT


Patient Name ____________________________________________________

I, __________________________________________________, the undersigned, patient/guardian understand that it is my right to elect the home care provider of my choice. I have selected AGENCY’S NAME GOES HERE free of any undue pressure or solicitation by any employee of AGENCY’S NAME GOES HERE and further declare that my receipt of home care services from AGENCY’S NAME GOES HERE is by choice. I have been advised by the admitting nurse that if for any reason I wish to change services to another home care agency, it is my right to do so.


PATIENT TRANSFER STATEMENT

(To be completed by all patients transferring from other agencies)

Not applicable


_______________________________________ the undersigned patient/guardian for,

Hereby requests that home health services be transferred from______________________________ to AGENCY’S NAME GOES HERE

Verify reason(s) for this request is:


I believe AGENCY’S NAME GOES HERE will better serve me.


I wish to be served by ________________________________ a nurse/aide employed by .

Other (explain): ____________________________________________________________________________________________________________________________________________________________


I am making this request of my own free will and have not been coerced, solicited, or pressured to do so by any employee of AGENCY’S NAME GOES HERE.



AGENCY’S NAME GOES HERE PATIENT CHOICE STATEMENT PATIENT NAME AGENCY’S NAME GOES HERE PATIENT CHOICE STATEMENT PATIENT NAME

Signature of patient/Guardian Date


AGENCY’S NAME GOES HERE PATIENT CHOICE STATEMENT PATIENT NAME AGENCY’S NAME GOES HERE PATIENT CHOICE STATEMENT PATIENT NAME

Signature of Patient /Guardian Date


HARVEST OF HOPE GALA IS THE AGENCY’S MOST SIGNIFICANT
MEDIUMSIZED PROJECT PROPOSAL 40176 REQUEST FOR GEF FUNDING AGENCY’S
NOTABLE CASE A7465 AGENCY’S FAILURE TO PROPERLY APPLY


Tags: patient choice, of patient, patient, statement, choice, agency’s