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13. Receive all services as outlined in the plan of care.
14. Have a confidential clinical record, and to have access to or to request the release of information in your clinical
record in accordance with the HIPPA Privacy Rule and as outlined in your Notice of Privacy Practices.
15. Be advised of the extent to which payment for home health services may be expected from Medicare,
Medicaid, or any other Federally-funded or Federal aid program known to the home health agency.
16. Be advised of the charges for services that may not be covered by Medicare, Medicaid, or any other Federally-
funded or Federal aid program known to the home health agency.
17. Be advised of the charges the individual may have to pay before care is initiated.
18. Be advised of any changes in the information provided related to service coverage. The home health agency
must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next
home health visit.
19. Receive proper written notice, in advance of a specific service being furnished, if the home health agency
believes the service may be non-covered care.
20. Receive proper written notice in advance of the home health agency reducing or terminating on-going care.
21. Be advised of the State toll-free home health telephone hot line, its contact information, hours of operation,
and that its purpose is to receive complaints or questions about local home health agencies.
22. Be advised of the names, addresses, and telephone numbers of the following Federally-funded and State-
funded entities that serve the area where the patient resides:
 Agency on Aging;
 Center for Independent Living;
 Protection and Advocacy Agency;
 Aging and Disability Resource Center;
 Quality Improvement Organization.
23. Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the home
health agency or an outside entity.
24. Be informed of your rights under state law to formulate Advance Directives.

SAMPLE
As a patient of this agency, you have the responsibility to:

1. Provide a complete and accurate health history and/or insurance/financial information.

2. Remain under the care of a licensed physician during your home health program.

3. Notify the Agency of any change in physician or insurance coverage.

4. Communicate any changes in your health status or treatment to the home health staff.
5. Treat Agency personnel with dignity and respect without discrimination.

6. Provide a safe environment for staff; secure animals and/or weapons.

7. Notify the Agency if you wish to cancel services and/or prescribed treatments.

8. Notify the Agency if you will be unavailable for a scheduled visit.

9. Accept the consequences for any refusal of treatment or choice of noncompliance.
10. Inform the health care provider of any complication or side effect of prescribed treatment.

11. Adhere to the plan of care which you participate in developing.

12. Notify and provide the Agency with any Advance Directive forms, and any changes made to such forms.