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PATIENT CHOICE FORM

Dear Patient and Family

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Your physician has ordered/recommended continued services after you leave our inpatient care.

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You have the right to select any provider to provide the care ordered/recommended by your physician. This is your choice. If you have insurance, they may designate a selected network of providers for you depending on the care needed. We have provided a list of agencies below to assist you in making your decision. Please indicate the agency you have selected on this form. Each agency includes their current Medicare Star rating as well as their self reported readmission rate and length of stay.

Activa Home Care

average rating is 4 out of 5

27 day length of service / 10% readmission rate*

Encompass Home Health

average rating is 4 out of 5

21 day length of service / 9% readmission rate*

Hospital without Walls

average rating is 4 out of 5

30 day length of service / 12% readmission rate*

Options Home Care

average rating is 4 out of 5

17 day length of service / 5% readmission rate*

VIP Physical Therapy

average rating is 4 out of 5

45 day length of service / 3% readmission rate*

Other:

I have been provided information by the facility to make this decision. I have been included in the planning for the care I will need after leaving the facility and agree with the care that is being arranged.

Patient or Patient Representative:

Electronically signed by: Darrell Smith

4/8/2020 11:38am

Last Updated Today

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