I understand that by signing this agreement, I hereby give consent for the care and services given to me by Helms Home Care, LLC. I also understand that these services are provided as ordered and directed by my physician and that Helms Home Care, LLC is not liable for any act or omission when following these orders. I understand that my care is under the supervision and control of my attending physician, and I consent to all medical treatments, procedures, examinations and tests reasonably necessary for my proper care.

I understand that Helms Home Care, LLC has a nurse available on-call, but is not an emergency services provider. I understand Helms Home Care, LLC will make every effort to provide nursing visits on time as scheduled and in accordance with my Plan of Treatment, but does not guarantee services or nursing availability. I understand that I am encouraged and asked to participate in the care planning process and may request to review my Plan of Treatment at any time.

I hereby authorize Helms Home Care, LLC to release copies of my medical records, or such portions thereof as may be relevant, to hospitals, physicians, insurance providers, other health or social service agencies or facilities to which I may be referred, transferred or who may be involved in my care as necessary, for the purpose of continuing coordination or reviewing my care. I further authorize any and all physicians and/or health care facilities which have rendered me care and services in the past to release all medical information to Helms Home Care, LLC when necessary to establish or continue my plan of care. I have been advised that certain governmental, licensing and accrediting bodies may conduct reviews of my records as part of survey processes and in regards to release of my medical information, records, or other confidential information to agents of the Department of Human Resources, Division of Facility Services, Division of Medical Assistance, etc. or other medical agencies that I have the right to object in writing to the release of such information.

I understand that Helms Home Care, LLC is not authorized or responsible for contacting my insurance provider to obtain prior authorization of benefits or payment for services rendered. I understand that Helms Home Care, LLC will not bill me or my insurance provider directly and that payment of any authorized benefits for services rendered by Helms Home Care, LLC is the responsibility of my attending pharmacy. I understand that Helms Home Care cannot speak with me about insurance benefits or answer financial questions related to care, services, or supplies related to my therapy. I agree to contact my pharmacy provider and/or insurance provider for all financial related concerns. I further understand that this assignment of benefits does not relieve me or other responsible parties of any liability, co-pays, or out-of pockets costs related to my therapy.

I understand that Helms Home Care, LLC does not carry or provide insurance coverage for damages to my automobile or other property resulting from the use of my automobile by a Helms Home Care, LLC employee. I agree not to allow or ask any Helms Home Care, LLC employee or representative to operate my automobile or transport me in a Helms Home Care, LLC employee's automobile. I hereby release Helms Home Care, LLC and its employees and hold them harmless and indemnify them from any claim, liability, or cause of action or any injury to my person or property resulting from the use of an automobile (whether or not owned by me) if operated by a Helms Home Care, LLC employee.

I have received a copy of the Helms Home Care "Welcome to Home Infusion Therapy" brochure which includes this consent agreement along with: (1) Agency contact information, when to call my MD or 911, (2) Infection Control instructions (3) Medication Storage instructions, (4) Patient Rights & Responsibilities, (5) Privacy Notice, (6) Emergency Preparedness information (7) Advance Directives information and (8) the Home Health Hot line and how to file a complaint. I have reviewed this information and had the opportunity to ask and have my questions and concerns regarding these answered.

The name & phone number of my Emergency Contact in the event I am unable to be reached or speak is listed below. I authorize the Agency to discuss my nursing schedule and care with this individual.

Name and address of the representative authorized to make medical decisions on my behalf is: