Supplement D: Admissions Checklist Medicare-Specific Issues (If Applicable) Medicare as Second Payor - Screening Questionnaire Waiver of Medicare Benefits (Optional) Complete Form Notice of Non-Coverage Under Medicare Provide One Copy to Resident/Authorized Representative Keep One Copy for Facility Records Determination on Admission Determination on Continued Stay Technical Denial Intermediary Decision Advanced Beneficiary Notice Advance Directives (Optional) Illinois Statutory Form Power of Attorney for Health Care Illinois Living Will Declaration Complete Form and Obtain Signatures Certification for Surrogate Decision-Making (With Provide One Copy to Resident/Authorized Representative Qualifying Conditions) Keep Original for Facility Records Forward One Copy to the Resident’s Chart Certification for Surrogate Decision-Making (Without Qualifying Conditions) Complete Form and Obtain Signatures Practitioner Order for Life-Sustaining Treatment Provide One Copy of form plus IDPH Guidance to (POLST) and Uniform Do-Not-Resuscitate (DNR) Resident/Authorized Representative IDPH Advance Directive Guidance for Individuals Keep Original for Facility Records (POLST & DNR) Forward One Copy to the Resident’s Chart I acknowledge that the areas of this checklist that have been marked have been explained to me in terms that I understand. I have been provided with an opportunity to ask questions, and those questions have been answered to the best of the facility’s ability. Additionally, I have received copies of all appropriate handouts and supplemental materials. ________________________________________________ __________________ Signature of Resident/Authorized Representative Date Supplement E: Arbitration Agreement ARBITRATION AND LIMITATION OF LIABILITY RIDER TO RESIDENCY AGREEMENT BETWEEN
Supplement D: Admissions Checklist Medicare-Specific Issues (If Applicable) Medicare as Second Payor - Screening Questionnaire Complete Form Provide One Copy to Resident/Authorized Representative Keep One Copy for Facility Records Waiver of Medicare Benefits (Optional) Notice of Non-Coverage Under Medicare Determination on Admission Determination on Continued Stay Technical Denial Intermediary Decision Advanced Beneficiary Notice Advance Directives (Optional) Illinois Statutory Form Power of Attorney for Health Care Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records Forward One Copy to the Resident’s Chart Illinois Living Will Declaration Certification for Surrogate Decision-Making (With Qualifying Conditions) Certification for Surrogate Decision-Making (Without Qualifying Conditions) Practitioner Order for Life-Sustaining Treatment (POLST) and Uniform Do-Not-Resuscitate (DNR) IDPH Advance Directive Guidance for Individuals (POLST & DNR) Complete Form and Obtain Signatures Provide One Copy of form plus IDPH Guidance to Resident/Authorized Representative Keep Original for Facility Records Forward One Copy to the Resident’s Chart I acknowledge that the areas of this checklist that have been marked have been explained to me in terms that I understand. I have been provided with an opportunity to ask questions, and those questions have been answered to the best of the facility’s ability. Additionally, I have received copies of all appropriate handouts and supplemental materials. ________________________________________________ __________________ Signature of Resident/Authorized Representative Date Supplement E: Arbitration Agreement ARBITRATION AND LIMITATION OF LIABILITY RIDER TO RESIDENCY AGREEMENT BETWEEN
Resident%20and%20Facility%20Contract.docx