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.Signature of Resident or Responsible Party* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Name* First Last Relationship* Share this:FacebookTwitterLinkedIn
