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English to Spanish: Authorization Document for BROADWAY RESPITE AND HOME CARE General field: Medical Detailed field: Medical: Health Care
Source text - English BROADWAY RESPITE AND HOME CARE
24-20 Broadway Avenue Fair Lawn, NJ 07410 Telephone: 201-703-3980
Authorization for Services
Consent for Treatment
I authorize BROADWAY RESPITE AND HOME CARE and its employees to provide home care services. I authorize healthcare personnel to examine me in order to determine whether I am eliglible for the level of care offered by BROADWAY RESPITE AND HOME CARE.
Client Ri hts Statement
I have received and reviewed the Client Rights and Responsibilities statement and I acknowledge that I can refuse care or services at any time.
Advance Directives
Advance Directives are written instructions to be carried out in the event you are unable to make your own healthiare decisions. The Agency does not require that you have an Advance Directive in oidet• to receive services. However, the Agency must provide you with written information about Advance Directives. I acknowledge that I have received written information about Advance Directives from the Agency.
I have a medical durable power of attorney (DPOA) or Healthcare Name and phone number of DPOA or Healthcare proxy, if applicable.
Proxy Yes No
In the event I stop breathing or my heart stops beating, I want to receive emergency services. Yes No
if I do not want to recéive emergency services, the Agehcy witl.hétp me obtain a "Do Not Resuscitate" order from my physiciah. I understand that Agency employees are legally obligated to contact emergency services unless I have a signed document from my physician. This order is neededtozptotect me and the Agency.
I also give BROADWAY RESPITE AND HOME CARE permission tb act on my behalf during medical emergencies until my guardian or designee arrives.
Scheduling of Services
BROADWAY RESPITE AND HOME CARE will make every effort to provide uninterrupted setvices and will notify me or my family, in a timely manner, when unable to provide services. In the event this situation arises, my back-up plan is to:
Trans ortation and Drivin of Client b Caregivers
BROADWAY RESPITE AND HOME CARE does not provide transportation services. If a client accepts transportation services from the caregiver, these services are not authorized by the Agency. The Agency disclaims any liability or financial responsibility to the client for personal injuries or property damage caused by negligent conduct while driving with a BRHC caregiver.
Com laint Process
BROADWAY RESPITE AND HOME CARE strives to provide effective home care services. In the event you have a complaint about your caregiver, services, billing, or scheduling, contact the Executive Director at the phone number listed above. The Executive
Director will contact you within 24 hours to determine the nature of the problem and will work with you to find a reasonable solution to the problem. If you are not satisfied with the solution, the Executive Director and Agency Administrator will discuss the problem and the Agency Administrator will contact you with a solution. If the Agency is unable to resolve the problem to your satisfaction, you have the right to discontinue services. Further, you may tile a complaint with the State of New Jersey, Division of Consumer Protection at 1201-504-6200.
Notice of Privac Practices
acknowledge receipt of the HIPAA required Notice of Privacy Practices. You do not have to acknowledge receipt of the Notice of Privacy Practices. However, the BRHC employee must document that you were provided the information and would not sign.
Home Safet and Emer enc Pre aredness
acknowled e recei t of Home Safet and Emer enc Pre aredness information
Client]Guardian's/DPOA Si nature Date
BRHC Em 10 eets Si nature Date
•
I
I
1 .Must have Staff With compliants call Joint Commission
2.Can wait 2 days for Staff on Accrreditation, Office of Quality
3.Has alternate arrangements, telephone numbers of local Police Dpt. Monitoring at 1-800-994-6610
Translation - Spanish BROADWAY RESPITE AND HOME CARE
24-20 Broadway Avenue Fair Lawn, NJ 07410 Telephone: 201-703-3980
Autorización De Servicios
Consentimiento Para Tratamiento
Yo autorizo a BROADWAY RESPITE AND HOME CARE y sus empleados a proveerme con los servicios de cuidado en el hogar. Yo autorizo al personal al cuidado de la salud a que examinen para que se pueda determinar mi elegibilidad al nivel de cuidados ofrecidos por BROADWAY RESPITE AND HOME CARE.
Declaración de Derechos del Cliente
He recibido y revisado la Declaración de Derechos y Responsabilidades del Cliente y reconozco que me puedo rehusar a recibir los cuidados o servicios en cualquier momento.
Declaración de Voluntades Anticipadas
La Declaración de Voluntades Anticipadas es un conjunto de instrucciones escritas que deben llevarse a cabo en caso de que usted no pueda tomar sus propias decisiones sobre el cuidado de su salud. Esta Agencia no requiere que usted tenga una Declaración de Voluntades Anticipadas para poder recibir sus servicios. No obstante, a esto, la Agencia tiene la obligación de proveerle información por escrito sobre Voluntades Anticipadas. Reconozco que he recibido información por escrito sobre Voluntades Anticipadas de esta Agencia.
Yo tengo un poder de representación legal para la atención médica o el nombre y número de teléfono del albacea del poder de representación legal para la atención médica (PDRLAM) o Procurador de Servicios de Salud, si aplica.
Procurador Si ☐ No ☐
En caso de deje de respirar o que mi corazón deje de latir, deseo recibir los servicios de emergencia. Si ☐ No ☐
De no desear recibir los servicios de emergencia, la Agencia me asistirá en obtener una Orden de No Resucitar, de mi médico. Entiendo que los empleados de la Agencia, están obligados por ley a contactar los servicios de emergencia necesarios, a menos que tenga un documento firmado por mi médico, ordenando lo contrario. Esta orden es necesaria para protegerme a mí y a la Agencia.
Yo, además, autorizo a BROADWAY RESPITE AND HOME CARE, a actuar en mi beneficio durante las emergencias médicas hasta que mi representante autorizado o designado, este disponible.
Coordinación de Servicios
BROADWAY RESPITE AND HOME CARE hará todo cuanto sea posible para proveer sus servicios sin interrupción y me notificará a mi o mi familia, con suficiente anticipación, cuando no sea posible brindar dichos servicios. De ocurrir una situación que lo amerite, mi plan de acción alterna es:
Transportación y Traslado de Clientes a sus Proveedores de Cuidado
BROADWAY RESPITE AND HOME CARE no provee servicios de transportación. De un cliente aceptar servicios de transportación de sus Proveedores de Cuidado, estos servicios no están autorizados por la Agencia. La Agencia niega cualquier responsabilidad, incluso responsabilidad financiera con el cliente por cualquier daño físico o a la propiedad de este, causada por conducta negligente mientras se le traslada a un Proveedor de Cuidado de BROADWAY RESPITE AND HOME CARE.
Proceso Para Quejas
BROADWAY RESPITE AND HOME CARE aspira a proveer servicios de cuidado en el hogar efectivos. De usted tener alguna queja sobre su Proveedor de cuidado, servicios, facturación o coordinación de servicios, por favor contacte al Director Ejecutivo al número que aparece arriba. El Director Ejecutivo se pondrá en contacto con usted dentro de las próximas 24 horas para determinar la naturaleza de su problema y trabajará con usted para encontrar una solución razonable a su problema. De no estar satisfecho con la solución, el Director Ejecutivo y Administrador de la Agencia discutirán el problema y el Administrador de la Agencia se pondrá en contacto con usted con una solución. Si la Agencia no es capaz de resolver el problema para su satisfacción, usted tiene el derecho de descontinuar nuestros servicios. En ese caso, usted podrá presentar una queja con el Estado de Nueva Jersey, ante la División de protección al Consumidor llamando al número 1-787-504-6200.
Notificación sobre Política de Privacidad
Yo acuso recibo de la Notificación sobre la Política de Privacidad requerida por la ley HIPPA. Usted no tiene que acusar recibo de Notificación sobre la Política de Privacidad. Pero en ese caso, nuestro empleado tendrá que documentar que se le proveyó la información y usted se negó a firmar por ella.
Seguridad en el Hogar y la Preparación para Emergencias
Yo acuso recibo de la información sobre la Seguridad en el Hogar y la Preparación para Emergencias
Firma del Cliente/Representante Autorizado/Albacea del (PDRLAM) Fecha
Firma del Empleado de BROADWAY RESPITE AND HOME CARE Fecha
1 Debe tener personal disponible.
2 Puede esperar 2 días por el personal.
3 Tiene arreglos alternos y el Numero dela Policía Local
Para presentar quejas llame a la Comisión Conjunta de Acreditaciones, Oficina de Control de
Calidad al 1-800-994-6610
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Experience
Years of experience: 8. Registered at ProZ.com: Jul 2016.
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