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GALAXY
  • Home
  • About
  • Services
    • Skilled Medical Services
      • Prescription Refill and Management
      • Open Wound Dressing
      • Ostomy Care
      • Catheter Care
      • G-Tube Feeding
      • Vital Signs Monitoring And Report To PCP Doctor
      • Safety Supervision
      • Symptom Monitoring
      • Mobility Support
    • Speech Therapy
      • Evaluation/Diagnosis/Prevention of speech impairment
      • Swallow evaluation and management
      • Speech fluency/ articulation
      • Cognitive communication
    • Medical Social Worker
      • Providing adequate resources for clients in the community
      • Short/long term planning of care
      • Adequate clients follow up
    • Home Health Aide
      • Medication reminders
      • Personal Care; Bed bath, using lift.
      • Vital signs monitoring & Report to Clinical Nurse
      • Certain housekeeping
      • Safety Supervision during Seizure
      • Symptom monitor and report to Clinical Nurse
      • Mobility support
    • Physical Occupational Therapy
      • Restore Function
      • Improve Mobility & Strength
      • Aid inside/outside ambulation
      • Range of motion, Positioning & Transfers
      • Control disabilities
      • Balancing & Gait
      • Promote ADL functions
      • Create an exercise plan
      • Promote Overall fitness
  • Forms
    • Administrator Competency & Job Description Form
    • Clinical Manager Job Description Form
    • Home Health Aide Competency & Job Description & Skill Validation
    • LPN Competency Job Description Form
    • MSW Competency Job Description Form
    • Occupational Therapist Assistant Job Description Form
    • Occupational Therapist Job Description Form
    • Physical Therapist Assistant Job Description Form
    • Physical Therapist Job Description Form
    • RN Job Description & Performance Evaluation & Competency Form
    • Speech Therapist Job Description Form
  • Resources
  • Employement
  • SanData
    • EVV
GALAXY > Aurora Adult Day Program

Aurora Adult Day Program

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MM slash DD slash YYYY
Services Agreement

I would like to be a participant in Aurora Adult Day Program. I have received an explanation of the services that will be provided to me, a facility tour, and understand that I have the right to participate in activities of my choosing.

Authorization for Release of Information

I hereby consent and authorize the Agency to release and receive information for the purposes of treatment, payment, and health care operations. The exchange of information may occur between, but is not limited to, physicians, third party payers, other health providers, and regulatory and/or accrediting reviewers

Statement to Permit Payment for Home Health Services

I hereby request that payment of authorized adult day program services be made on my behalf to the Agency.

I understand that agency will bill(Required)
Consent(Required)
(Required)
Acknowledgements

I have received verbal and written information on the following, and have had the information explained to me:

  • 1. Participant Handbook Facility rules
  • 2. Emergency Preparedness, Infection Control and Safety Education
  • 3. Facility Tour
  • 4. Orientation to policy and procedures
Advance Directives(Required)
I have the following(Required)
Other Advanced Directives(Required)
Copy obtained

I certify that I have read and agree with the information on this document and have been provided a copy for my records. I have participated in the formation of my plan of care.

MM slash DD slash YYYY
MM slash DD slash YYYY

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Unit 118, Aurora, CO 80012
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Copyright © 2022 GalaxyHomeHealth All rights reserved | Design & Developed by GrowSmart
  • Home
  • About
  • Services
    • Skilled Medical Services
      • Prescription Refill and Management
      • Open Wound Dressing
      • Ostomy Care
      • Catheter Care
      • G-Tube Feeding
      • Vital Signs Monitoring And Report To PCP Doctor
      • Safety Supervision
      • Symptom Monitoring
      • Mobility Support
    • Speech Therapy
      • Evaluation/Diagnosis/Prevention of speech impairment
      • Swallow evaluation and management
      • Speech fluency/ articulation
      • Cognitive communication
    • Medical Social Worker
      • Providing adequate resources for clients in the community
      • Short/long term planning of care
      • Adequate clients follow up
    • Home Health Aide
      • Medication reminders
      • Personal Care; Bed bath, using lift.
      • Vital signs monitoring & Report to Clinical Nurse
      • Certain housekeeping
      • Safety Supervision during Seizure
      • Symptom monitor and report to Clinical Nurse
      • Mobility support
    • Physical Occupational Therapy
      • Restore Function
      • Improve Mobility & Strength
      • Aid inside/outside ambulation
      • Range of motion, Positioning & Transfers
      • Control disabilities
      • Balancing & Gait
      • Promote ADL functions
      • Create an exercise plan
      • Promote Overall fitness
  • Forms
    • Administrator Competency & Job Description Form
    • Clinical Manager Job Description Form
    • Home Health Aide Competency & Job Description & Skill Validation
    • LPN Competency Job Description Form
    • MSW Competency Job Description Form
    • Occupational Therapist Assistant Job Description Form
    • Occupational Therapist Job Description Form
    • Physical Therapist Assistant Job Description Form
    • Physical Therapist Job Description Form
    • RN Job Description & Performance Evaluation & Competency Form
    • Speech Therapist Job Description Form
  • Resources
  • Employement
  • SanData
    • EVV
  • Form