• Skip to primary navigation
  • Skip to main content
  • Skip to footer

Maunalani Nursing & Rehab Center

Climbing the heights for you...

Email: info@maunalani.org
Phone: (808) 732-0771
  • Home
  • About Us
    • About Maunalani
    • Mission, Vision, & Values
    • The Maunalani Experience
    • Employment Opportunities
    • Employment Application
    • Friends of Maunalani
  • Services
    • Services Overview
    • Rehabilitation Services
    • Skilled Nursing
    • Clinical Care
    • Hospice Palliative Care
  • Amenities
    • Available Amenities
    • Recreational Activities
    • Dining
    • Events
  • Admissions
    • Admissions Details
    • FAQs
  • What’s New…
  • Contact
  • CoronaVirus Updates
You are here: Home / Intake Forms / Intake Forms- Identifying Other Primary Payers During the Admission Process

Intake Forms- Identifying Other Primary Payers During the Admission Process

July 18, 2011 By Maunalani Staff

  • MAUNALANI NURSING AND REHABILITATION CENTER

    RESIDENT CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST

    I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for the determination of Medicare benefits. I request that payment of authorized benefits be made on my behalf to Maunalani Nursing and Rehabilitation Center.

    ELECTRONIC TRANSMISSION OF RESIDENT CARE INFORMATION

    All Medicare/Medicaid certified long-term care facilities are mandated to electronically transmit patient care information to the State database. This information, in turn, will be forwarded to the Centers for Medicare & Medicaid Services (CMS).

    Maunalani Nursing and Rehabilitation Center is required to inform you of the purpose and uses of information being collected. A copy of the Privacy Act Notification Statement, which summarizes this requirement, is included in the Resident Manual under the section Notices.

    Please sign below to acknowledge receipt of this information.

  • MM slash DD slash YYYY

Share this:

  • Facebook
  • Twitter
  • LinkedIn

Filed Under: Intake Forms Tagged With: Intake Forms

Footer

Maunalani Nursing and Rehabilitation Center

5113 Maunalani Circle
Honolulu, HI 96816
Phone: (808) 732-0771
Email: info@maunalani.org

Copyright © 2023 · Handcrafted by HawaiiWP.com LLC · Log in