Form F-62369 "Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (Cbrf)" - Wisconsin

What Is Form F-62369?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2009;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-62369 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-62369 "Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (Cbrf)" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Page 1 of 2
F-62369 (Rev. 04/09)
WAIVER OF HOSPICE OR HOME HEALTH SERVICES
BY A TERMINALLY ILL RESIDENT OF A COMMUNITY BASED RESIDENTIAL FACILITY (CBRF )
Completion of this form by the resident is voluntary per DHS 83.38(2)(b), Wis. Admin. Code.
Name – Resident
Date
Name – CBRF
Telephone Number
Address
City
State
Zip Code
A terminally ill resident of a Community Based Residential Facility (CBRF) may waive the
requirement that he or she receive the services of a Hospice Program or a Home Health Agency for
his or her terminal illness while continuing to reside in the CBRF. It is important for the resident or
his or her guardian or agent to make an informed decision on whether or not to waive services from
these agencies. An agent of the resident can be the person designated in the power of attorney for
health care document that has been activated. (This may include durable power of attorney
documents that gave health care decision making powers to an agent.)
Therefore, prior to waiving these services, the CBRF must ensure that the resident and his or her
guardian or agent are provided with information about the type of services generally offered by a
Hospice Program or Home Health Agency. The CBRF must provide an opportunity to:
1. Speak with a representative of a Hospice Program or Home Health Agency.
2. Review literature for a Hospice Program or Home Health Agency which
describes its services to a terminally ill person.
If the services of a Hospice Program or Home Health Agency are waived by the resident or his or
her guardian or agent, the CBRF is required to coordinate all of the care and services for the
terminally ill resident.
The resident or the resident and his or her designated representative, or his or her guardian or
activated health care agent may, at any time, revoke this waiver and receive services from a
Hospice Program or Home Health Agency by signing the Revocation of Waiver on the second page
of this form.
Having been provided the opportunity to speak with a representative of a Hospice Program or
Home Health Agency and review literature from at least one of these agencies, I hereby waive the
services of a Hospice Program or Home Health Agency.
Date Signed
SIGNATURE
- Resident (and designated representative, if previously requested by resident in writing)
OR
Date Signed
SIGNATURE
- Guardian or Agent
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Page 1 of 2
F-62369 (Rev. 04/09)
WAIVER OF HOSPICE OR HOME HEALTH SERVICES
BY A TERMINALLY ILL RESIDENT OF A COMMUNITY BASED RESIDENTIAL FACILITY (CBRF )
Completion of this form by the resident is voluntary per DHS 83.38(2)(b), Wis. Admin. Code.
Name – Resident
Date
Name – CBRF
Telephone Number
Address
City
State
Zip Code
A terminally ill resident of a Community Based Residential Facility (CBRF) may waive the
requirement that he or she receive the services of a Hospice Program or a Home Health Agency for
his or her terminal illness while continuing to reside in the CBRF. It is important for the resident or
his or her guardian or agent to make an informed decision on whether or not to waive services from
these agencies. An agent of the resident can be the person designated in the power of attorney for
health care document that has been activated. (This may include durable power of attorney
documents that gave health care decision making powers to an agent.)
Therefore, prior to waiving these services, the CBRF must ensure that the resident and his or her
guardian or agent are provided with information about the type of services generally offered by a
Hospice Program or Home Health Agency. The CBRF must provide an opportunity to:
1. Speak with a representative of a Hospice Program or Home Health Agency.
2. Review literature for a Hospice Program or Home Health Agency which
describes its services to a terminally ill person.
If the services of a Hospice Program or Home Health Agency are waived by the resident or his or
her guardian or agent, the CBRF is required to coordinate all of the care and services for the
terminally ill resident.
The resident or the resident and his or her designated representative, or his or her guardian or
activated health care agent may, at any time, revoke this waiver and receive services from a
Hospice Program or Home Health Agency by signing the Revocation of Waiver on the second page
of this form.
Having been provided the opportunity to speak with a representative of a Hospice Program or
Home Health Agency and review literature from at least one of these agencies, I hereby waive the
services of a Hospice Program or Home Health Agency.
Date Signed
SIGNATURE
- Resident (and designated representative, if previously requested by resident in writing)
OR
Date Signed
SIGNATURE
- Guardian or Agent
F-62369 (Rev. 04/09)
Page 2 of 2
REVOCATION OF THE WAIVER OF HOSPICE OR HOME HEALTH SERVICES
I hereby revoke the waiver on the opposite side of this form
so that I may receive the services of a Hospice Program or Home Health Agency.
Date Signed
SIGNATURE
– Resident (and designated representative, if previously requested by resident in writing)
OR
Date Signed
SIGNATURE
- Guardian or Agency
Page of 2