Disclosure of Services & Release of Information Statement-Washington

It is important for us to comply with the Elder & Vulnerable Adult Referral Agency Act of April, 2011. Please acknowledge that you have read and understand this document by typing your name in the signature box below and then click on “Submit”. If you prefer, you can click on “Download as PDF” so you can then print out the form, read, sign and either 1) scan and send the completed document to support@btss.co or 2) fax the signature page to 619-765-3040.

Best Senior Care Choices by: Beyond the Sky Solutions (BTSS) is a professional caregiver training, senior care placement and consulting agency with our corporate office located at 333 H Street, Ste. 5000 Chula Vista, CA 91910. More information visit www.bestseniorcare.co or by calling 1(888) 294-1488.

DISCLOSURE OF SERVICES: BTSS is a non-medical information service. We do not offer medical advice or services. The agency is comprised of representatives with the title of Senior Care Consultants (SCC), providing placement services in the states of California and Washington. Each representative is background checked and trained to provide services. BTSS/SCCs work with CLIENTs and providers to deliver services. In order to do so, and comply with HIPPA regulations; SCCs will request CLIENT’s authorization to disclose confidential health information to providers. SCCs deliver CLIENT with placement services by assisting CLIENT in finding appropriate senior care by either giving the CLIENT names and addresses of recommended senior care housing or home care; or by giving a provider the name of the CLIENT after obtaining the authorization of the CLIENT or CLIENT’S representation.

 It is the responsibility of the SCC to give the most accurate information available on recommended senior care housing and/or resources. Prior to making a referral to a specific provider, SCC shall speak with a representative of the provider and obtain general information on provider in accordance with chapter 18.330.070 RCW for SCC to make appropriate recommendations. It is the responsibility of the SCC to visit senior housing options prior to making recommendations. Prior to provider becoming listed in BTSS database as an option for CLIENTs, all provider profile information is obtained from appropriate authorities such as DSHS/DOH. The SCC provides recommendations to CLIENT but does not make the final decision selecting any particular option. It is NOT the responsibility of the SCC to negotiate applicable move-in, monthly rent or care fees with the care provider. In the state of Washington, BTSS does not require CLIENTs to sign waivers of potential liability for losses of personal property or injury, or to sign waivers of any rights of the CLIENT established in state or federal law.


INTAKE FORM
: BTSS utilizes our “BEST-FIT” placement model during the intake process. This form meets the requirements of Washington State health care information confidentiality laws.  Once CLIENT agrees to obtaining the services of a SCC, the CLIENT is responsible for providing SCC with accurate information on potential resident’s health condition, background and ability to pay senior care fees. SCC will make senior care recommendations to providers who may meet the identified needs of the CLIENT based on information provided by CLIENT. SCCs do not select a specific provider on behalf of the CLIENT. The CLIENT must make the final decision.

 FEES: There are no fees paid by CLIENT to BTSS or SCC for placement services. BTSS signs contracts with various providers to receive a referral fee, usually based on a percentage of the first month’s rent and care fees of the CLIENT. BTSS receives referral fee after provider receives compensation from CLIENT for 30 days. We accept no referral fee from provider if any part of the monthly cost is paid by Medicaid. Should CLIENT become a Federal or State funded consumer, then the referral fee will be prorated to cover only the private pay portion of the stay. BTSS will then work on a private pay basis with family or friends of the senior. If CLIENT moves out or dies prior to 30 days, a pro-rate referral fee will apply to provider. By no means does this influence our judgement in recommending the “Best” options for the CLIENT.

 Assessments in the state of Washington:  In April of 2015, Washington State requires the completion of a specific type of pre-admission assessment by a qualified assessor prior to move-in to an adult family care home. Assessments for move-ins to assisted living do not require a person with specific professional designation. The contents of the assessment are dictated by the state of Washington. Many adult family care homes are owned and operated by registered nurses, nurse practitioners or other health care professionals. Many of them may offer to complete the pre-admission assessment at a charge or no charge at all.

 Mandated Reporters: State law requires all SCPCs to report suspected instances of abuse, neglect, abandonment or financial fraud to the appropriate authorities. Please be aware that the request of a CLIENT to not disclose abuse to authorities is against the law and not allowed by BTSS.

Termination: SCCs want to provide the best service possible and would like to know reasons for termination. However, you may end your relationship without explanation. If you wish to stop receiving assistance from SCC, you may do so by informing the SCC directly or by sending an email to support@btss.co or by calling BTSS at (888) 294-1488.

 Complaints: BTSS owners want to ensure the best services are provided and is always interested in knowing reasons for termination of support or if you believe services were not delivered with compassion. You are encouraged to call (619) 476-2239 and ask for Jatana Williams. She will listen to your suggestions on how to improve our services. If you feel BTSS has not complied with state laws protecting older or vulnerable adults, you may contact the Attorney General’s office in the state where you received services. As of April 2015, Washington is the only state with specific regulations regarding referral agencies.

 CONFIDENTIALITY OF PATIENT INFORMATION: BTSS and SCC will only have access to Health Insurance Portability and Accountability Act (“HIPAA”) information in connection with providing placement services when necessary. The purpose of this disclosure, at this time, is for both non-medical and for medical purposes. Further, there is the potential for the protected health information to be re-disclosed by the recipient and thus, no longer is protected under this Privacy Rule.

Download as PDF

I give the staff of BTSS and SENIOR CARE CONSULTANT ASSITING ME:
permission to access information regarding the older adult(s) named below in need of placement services. I also give permission to the providers working with BTSS (physicians, clinicians, ARNPs, licensed assessors, senior housing and care providers and/or paraprofessionals as well as regulatory or vulnerable adult advocacy organizations) to access this information as it relates to my interest in arranging for in-home care or relocating to an assisted living community, adult family home etc.

I confirm receipt of the Disclosure Statement & Information Release Form of Best Senior Care by: Beyond the Sky Solutions, LLC. contained in this document. I confirm that I am either the older adult seeking assistance or I am a family member or related to the older adult OR, I hold legal documents such as Power of Attorney or Guardianship to help the older adult(s).

Effective Date

Printed Name (required)

Contact Phone (required)

Email (required)

1) PRINTED NAME(S) of OLDER ADULT in of support (S):

Date of Birth:

2) PRINTED NAME(S) of OLDER ADULT in of support (S):

Date of Birth: