* = Required Information
RX Team Home Health Care LLC is a home health care agency. All the information asked is for statistical reasons and is strictly confidential to the full degree authorized by law. No distinguishing information will be issued without your consent. The information asked enables RX Team Home Health Care to assess every client for admissibility to our programs; hence, we ask you to complete answering the entire document.
Chosen Method(s) of contact
Yes No
Yes No
Yes No
No Contact
Single Married Living with Domestic Partner
Divorced Other
Heterosexual Homosexual
Male Female
Yes No
White Black/African American Asian
Multiracial Pacific Islander Hawaiian
Am. Indian/Alaska Native Unknown/Decline to Report Other
Hispanic Non-Hispanic
Yes No
Yes No
Yes No
Kindly supply your emergency contact information below.
Yes No
Primary Caregiver
(Individual in charge of providing the patient with day-to-day care. Suitable documentation must be presented.)
N/A, I do not have a primary caregiver.
Same as emergency contact
Legal Guardian
(Court-appointed individual who makes healthcare decisions on behalf of the patient. The necessary documentation must be presented.)
N/A, I do not have a legal guardian
Same as emergency contact
Health Care Proxy
(The individual appointed by the patient who makes healthcare decisions in their place. Suitable documentation must be presented.)
N/A, I do not have a health care proxy.
Same as emergency contact
Medical Information
No Yes
Do Not Resuscitate Medical Power of Attorney
Living Will
For Maternity Patient Only
No Yes
Answer the insurance questions below.
No Yes
Which type of health insurance do you have?
None/Self-Pay Military Medicare Plan
Medicaid Plan Private Insurance
Insured/Policy Holder's Information
Insured/Policy Holder's Information
How did you find out about our services?
Friend/Relative In Print On Radio/TV
Internet Referral Community Event

By signing this form, I confirm that all the statements I have provided, including my responses to all questions are accurate and honest to the best of my knowledge and belief. I assent to provide the eligibility staff with any information needed to verify statements about my eligibility. I recognize that supplying false information could lead to disqualification and repayment. If my income or the number of individuals in my family should change, I will inform the eligibility staff.

Adult Consent & Acknowledgment For Services
Accomplishment of this consent form is vital to provide services to a patient. While some items may not be applicable to your current situation, we ask that you complete this consent in its entirety in order for us to provide full care during this visit and in future visits. You have the benefit of rescinding this consent by giving written notice at any time.
Consent for Testing and Treatment
By initialing, I hereby grant permission to RX Team Home Health Care LLC to execute such assessments, treatments, and procedures as required by the medical staff for diagnostic and/or therapeutic purposes, which includes, but is not limited to, STD testing including but not limited to HIV. As a component of the testing and treatment, I may obtain disease-specific prevention, education, and risk-reduction services. State law requires RX Team Home Health Care LLC to disclose my name, address, treatment, and other information to the City of Houston Department of Health & Human Services for known persons who test positive for TB, HIV/AIDS, and syphilis. Individuals who test positive may be contacted by a Disease Intervention Specialist (DIS) to confirm they have been treated successfully and that sex partners who may be vulnerable of acquiring the disease have been notified about their potential risk.
Acknowledgment of Receipt
By initialing, I accept that RX Team Home Health Care LLC has supplied me with its Notice of Privacy Practices, which elaborates how my health information will be managed in different situations; Client Rights and Responsibilities, which I consent to abide by; Grievance Policy, for registering complaints; and E-Prescribing Information Sheet.
Financial Responsibility
By initialing below, I am aware that if I am qualified for services through a grant funded program such as Ryan White or the Department of State Health Services Family Planning (Title X), these resources are payers of last resort. This means that if I currently, or in the future, have Medicare, Medicaid, and/or third party insurance, I may not be entitled to services under these grants. Hence, I agree to promptly report any changes in my financial status and/or insurance coverage to the Eligibility Specialist. If such changes have not been properly reported and if those changes in my status give rise to my disqualification for services under a grant funded program at RX Team Home Health Care LLC, I recognize that I am wholly responsible for the cost of services provided by RX Team Home Health Care LLC.
Medicaid/Medicare/Third-Party Insurance
By initialing below, should I become qualified for Medicaid, Medicare, and/or third-party insurance while a client of RX Team Home Health Care LLC, I permit RX Team Home Health Care LLC to supply Medicaid and/or Medicare and/or a third-party insurer all of the essential medical information, including my HIV status, to process my claim.
By initialing below, I hereby appoint to RX Team Home Health Care LLC all payments from Medicaid, Medicare, and/or any other third party insurer for medical services given. I recognize that I am in charge of the cost of services delivered that are not included by my insurance. I also am aware that I may be accountable for my co-pay to be paid before I am examined by a healthcare practitioner.
Consent For Communication with Delegated Individual
By initialing, I permit RX Team Home Health Care LLC to communicate with the following individual regarding my health care, which may include information about my medical diagnosis, appointments, and eligibility status.
Terms of Consent
By signing below, I consent to the terms and information stated above. I am providing this approval of my own free will. I completely release RX Team Home Health Care LLC and the Harris County Public Health & Environmental Services, and Ryan White Grant Administration, as well as their Officers, Directors, Board Members, employees, and agents (i.e., volunteers, students) harmless from any and all losses, damages, obligations, liabilities (joint or several), claims, payments, penalties, demands, litigation, suits, defenses, proceedings, judgments, costs, disbursements or expenses (including without fees, disbursements, limitation, and expenses of attorney as well as other professional advisors and of expert witnesses and costs of investigation and preparation) of any kind or nature whatsoever relating to, arising out of, or resulting from my receipt of services.
I have had the occasion to raise any questions and have had them addressed in a language that I comprehend. Furthermore, I agree to adhere to the terms of this consent. I am aware that this document stays in effect until I rescind my consent in writing. I also understand that I am able to revoke my consent at any time.
Adult Medical History Form for Patient Completion
Yes No

Preventive Care (Write the date of your most recent)

Family History(Include Father [F], Mother [M], Sister [S], Brother [B], Grandfather [GF], Grandmother [GM])

Frequent or severe headaches Chest pain, difficulty breathing Redness, pain in legs
Numbness of arms or legs Kidney or bladder disease Stomach/bowel problems
Blurred or double vision Anemia Blood transfusions
High blood pressure High cholesterol Heart murmur/problem
Stroke Sickle cell trait disease Seizure disorder
Skin allergies/irritation Increase in thirst or urination Sores that do not heal
Swollen legs/ankles Birth defects Cancer
Unusual vaginal bleeding or discharge Abdominal/pelvic pain or infection Breast discharge/lump
Uterine fibroid or tumor HIV Liver problems
Hepatitis A, B, C Discharge from penis Herpes, warts syphilis, chlamydia, and/or gonorrhea
Yes No
N/A - Menopausal

Patient Mental Health Assessment

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Drug and Alcohol Use and History

Yes No
Yes No
Yes No
Yes No
Yes No

I have responded to all of the questions regarding my medical history and my present physical condition honestly and completely. I have informed the doctors or other designated health center personnel regarding any conditions I may have, which may influence my overall health care. It is my role to notify my provider if this information should change in the future. By signing below, I guarantee that I have answered and reviewed the complete four-page document. Any spaces left blank do not apply to me.

***By signing above, I certify that I have checked the whole two-page document and acquired clarification from the patient as needed. Any blank spaces in this history form must be lined through by the patient and initialed by the reviewing provider to establish that it is not relevant to the patient.***

Consent & Acknowledgment for Attaining e-prescribing History

Acknowledgment of Receipt of e-prescribing Information Sheet

By initialing, I accept that RX Team Home Health Care LLC has supplied me with its E-Prescribing Information Sheet, which discusses the purpose and specifics on how my prescriptions and prescription refill history will be managed electronically.

Terms of Consent

I am aware that providing RX Team Home Health Care LLC with my current and past prescriptions history will help the agency in verifying the safety of my prescriptions and lessening dangerous interactions with the other medications I may be taking.

I hereby consent to give RX Team Home Health Care LLC permission to acquire this medication history electronically from other healthcare organizations, which includes, but is not limited to, pharmacies.

I decline the option of supplying RX Team Home Health Care LLC with my current and past prescriptions history.

By signing below, I accept that I am accomplishing this consent of my own free will to consent as initialed above. I completely release RX Team Home Health Care LLC, their employees, Board Members, and agents (i.e., volunteers and students) harmless from any and all losses, damages, liabilities (joint or several), claims, litigation, payments, proceedings, and suits of any kind or nature whatsoever arising from out of my receipt of this service.

I am aware that this consent shall remain active until I retract my consent in writing at any time.

Consent for Review of Records for Research

RX Team Home Health Care LLC partakes in research studies, which include proven or experimental treatments. The RX Team Home Health Care LLC staff would like to examine your records to identify if you are eligible to be a part of current or future studies.

By signing this form, you are only signifying that you are willing to share the information found in your patient records with the RX Team Home Health Care LLC research staff. The lone objective of this information is to identify if you are eligible for a research study. You are not consenting to participate in a research study by signing this form.

This consent may be rescinded at any time, apart from the degree that action may already have been taken in reliance on it.