Bed Reserve Policy Notification Facility Bed Reserve % Provide One Copy to Resident/Authorized Representative Resident Fund Policy Notification and Authorization Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records Laundry Services Complete Form Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records Notification of Facility Policy Regarding Personal Property Provide One Copy to Resident/Authorized Representative Authorization to Inspect and Open Official Correspondence Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records Special Notifications: Resident Council Care Plan Conferences Participation in Resident Field Trips Special Notice to Families and Visitors Provide One Copy to Resident/Authorized Representative Audio, Video and Photographic Release Form Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records Financial Notifications and Information Assignment of Medicare Benefits and Authorization for Release of Information Obtain Information and Signatures Your Benefits Under Medicare Provide One Copy to Resident/Authorized Representative Your Benefit Rights and Eligibility Information Medicaid Choose the Appropriate Form, For Single Individuals or Married Couples With One Person in the Community) Provide One Copy to Resident/Authorized Representative Medicaid Services and Supplies Covered by the Illinois Medical Assistance Program Provide One Copy to Resident/Authorized Representative
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