infusion/specialty pharmacy intake packet · there may be two components to your infusion therapy:...

Infusion/Specialty Pharmacy Intake PacketConfidentiality Notice: Information contained on this site is proprietary in nature, and offered for the use of registered individuals only. You are hereby notified that any disclosure, copying, or distribution of the information is strictly prohibited.

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genevawoods.com

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WELCOME LETTER ....................................................................................................................................... 3-4

BLOOD AND BODILY FLUIDS PRECAUTIONS ........................................................................................ 5

SHARPS CONTAINER GUIDELINES ........................................................................................................... 6

STORAGE AND HANDLING OF SOLUTIONS ....................................................................................... 7-8

REVIEW OF INSTRUCTIONS BY NURSE - PATIENT COPY .................................................................. 9

PAGE LEFT INTENTIONALLY BLANK ........................................................................................................ 10

IV THERAPY PATIENT EDUCATION FORM – GWP COPY .................................................................. 11

AUTHORIZATION OF SERVICE/CARE, RENTAL/SALES TERMS, AND ASSIGNMENT OF BENEFITS ............................................................................................................ 12

ACKNOWLEDGEMENT OF MY FINANCIAL RESPONSIBILITY ........................................................... 13

HOME INFUSION PATIENT ACKNOWLEDGEMENT ............................................................................. 14

Table of Contents

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Welcome

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Welcome!Thank you for choosing Geneva Woods Pharmacy, Inc. as your home infusion and specialty pharmacy

provider. We are proud to be your pharmacy of choice and we look forward to serving you.

In order to provide services to new patients, we need a completed intake packet. Please provide as much

information as possible so we can effectively communicate with everyone involved in your medical care. If

certain information does not apply to you, please indicate that by noting “N/A” for “Not Applicable” so we

know nothing was missed. If at any time during the course of your treatment, you are planning to move,

your insurance(s) change, or any other significant life changes occur, please contact us as soon as possible

to ensure your services will not be disrupted.

Geneva Woods Pharmacy is also able to provide Home Medical Equipment as well as Retail and MedSet

Clinical Pharmacy services within the Anchorage and Mat-Su area. We will coordinate delivery of these

services conveniently to your home or choice of delivery location. If you are interested in any of these

additional services, please call our main line and ask to speak with a new patient service representative.

It is our goal to provide a one-stop, convenient service for all of your home health and medical needs.

Sincerely,

Your Geneva Woods Infusion and Specialty Pharmacy Staff

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Welcome

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Geneva Woods Professional Infusion and Specialty Pharmacy501 W International Airport Rd • Ste 4

Anchorage, AK 99518

8:30 am – 5:30 pm • Mon-Fri and on-call service after hours

907.565.6100 • 907.334.8587 Fax

Geneva Woods Mat-Su Pharmacy3674 E Country Field Cir

Wasilla, AK 99654

8:00 am – 6:00 pm • Mon-Fri and after hours

907.376.8200 • 907.352.5581 Fax

In-State Toll Free: 800.478.0005

There may be two components to your infusion therapy: pharmacy and nursing. During your medication

therapy, you may choose Geneva Woods trained infusion nurses to manage your care, or you may receive

nursing care from a clinic or home health agency nurse. In either case, our pharmacists and nurses will

coordinate services to bring you optimal care.

Our staff will contact you during the course of your therapy to check in, ask how you are feeling, and see if

you have questions or concerns regarding your therapy. We ask that you keep inventory of your supplies;

that way, if you become low, we are able to ship refills before they are depleted. If you need supplies at times

other than our scheduled deliveries, please call us and we will attempt to expedite an order.

We encourage patients to call our staff at any time. Our office hours are Mon-Fri 8:30-5:30. We also have

pharmacists and nurses on-call twenty-four hours a day, seven days a week, to address any urgent questions

or concerns that may arise. We suggest that you have your physician’s phone number close at hand, be

familiar with the location of the hospital and emergency room closest to you, and know that 911 should be

called in case of an emergency.

Please use the area below to write in important phone numbers.

Physician: ___________________________________________ Phone: _____________________________

Physician: ___________________________________________ Phone: _____________________________

Nursing Agency: ______________________________________ Phone: _____________________________

IN CASE OF EMERGENCY, CALL 911

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Blood & Bodily Fluid Precautions

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Nurses and family members that care for patients receiving home intravenous therapies should be careful when handling blood and other bodily fluids.

Thorough hand washing before and after caring for the patient cannot be over-emphasized to protect boththe patient and the caregiver from possible infections.

These are some examples of bodily fluids:Stool Blood specimensVomit BloodUrine Vaginal secretionsSaliva Wound drainageSputum Skin lesion drainageMucus Semen

Follow these directions when caring for patients and handling blood and bodily fluids:

1. Wash your hands thoroughly before and after patient contact, even if gloves are worn.2. While caring for the patient and handling patient equipment, do not touch your face or mouth.3. Wear gloves when in direct contact with any of the patient’s bodily fluids, or blood.4. Wear gloves when handling supplies that have been contaminated with a patient’s blood and/or bodily fluids.5. Wear a disposable gown when clothing is likely to be in contact with the patient’s bodily fluids.6. Use a mask if recommended by your home infusion nurse.7. All disposable articles contaminated with blood and/or other bodily fluids should be disposed of in a sealed plastic bag.8. Use household bleach to clean spills and to wash soiled clothes and linens.9. Do not bend, break, or recap used needles.10. Dispose of all used needles and syringes in a sharps container.


Sharps Containers

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If you received a sharps container:

DO NOT THROW AWAY YOUR SHARPS CONTAINER WITH NORMAL TRASH!When your sharps container is about ¾ full, it needs to be replaced. Please cap the top of the container securely and contact any of the facilities listed below. They will properly dispose of your sharps container free of charge.

ANCHORAGE___________________________________________________Entech Alaska 907.344.1535 Providence Laboratory Patient Service Center 907.644.8252

THE VALLEY___________________________________________________Bring your container to Matsu Regional Hospital Laboratory. They will switch out containers brought to them. Geneva Woods Pharmacy, Inc. does not pick up sharps containers.

DO NOT PUT FINGERS OR HANDS INTO THE OPENING OF THE SHARPS CONTAINER. PLEASE KEEP THE SHARPS CONTAINER OUT OF THE REACH OF CHILDREN.

If you received a sharps container:

DO NOT THROW AWAY YOUR SHARPS CONTAINER WITH

NORMAL TRASH!

When your sharps container is about ¾ full, it needs to be replaced. Please cap the top of the container securely. Then call either of the facilities listed. They will properly dispose of your sharps container free of charge.

ANCHORAGE

Entech Alaska 907-344-1535

Providence Laboratory Patient Service Center 907-644-8252


Storage and Handling of Solutions

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When your medication arrives, store it immediately. Please organize your medication so the older solutions are used before the newer ones. The expiration date of your medication is printed on the label attached to each unit of medication.

Your medication is supplied as a solution in either bags or elastomeric balls (also called “Eclipses”) made of strong plastic. However, they should be handled gently and protected from sharp objects.

If the bag or Eclipse leaks:

• DO NOT USE • Inform Geneva Woods Pharmacy, Inc. of the problem as soon as possible.

REFRIGERATION

Your solution may be delivered to you refrigerated, or frozen, depending on the medication. This is by design. If it comes to you refrigerated, keep it refrigerated and do not freeze. If it comes to you frozen, keep it frozen and do not refrigerate. We will explain the handling and storage in the sections below.

Storage and handling of REFRIGERATED solutions

• Keep the refrigerator at a temperature of 2°C to 8°C (36°F to 46°F).• Place the medication solutions in an area of the refrigerator that will be less likely to freeze.• Place the medication solutions in an area of the refrigerator isolated from food (e.g. separate shelf or drawer).• Remove from the refrigerator only the number of bags and/or Eclipses you intend to use for your next dose.• Before use, allow the medication to warm to room temperature, avoiding extreme heat and light. The medication label contains information regarding when to remove the medication from the refrigerator before use.• The solution unit may be cool to the touch when ready to use. Keep in mind that the time to reach room temperature depends on the medication, bag size and delivery device.• Do not warm the solution by using water baths or other direct sources of external heat, like a microwave oven, direct sunlight, or a radiator.• After warming, check the bag for leaks by squeezing it gently.• Minimize the exposure of solutions to room temperature for an extended period of time.

Unless labeled otherwise, refrigerated solutions must be used within 24 hours once removed from the refrigerator. If this is not done, the medication must be discarded.


Storage and Solutions continued...

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Storage and handling of FROZEN solutions

• The freezer should be at a temperature of -20°C to -10°C (-4°F to 14°F).• Remove enough solution from the freezer to supply for 24 hours. Thaw the frozen solution bags at room temperature, 21°C to 30°C (70°F to 74°F).• When thawing, place the solution bags in an area protected from extreme heat and light.• Do not thaw and warm the solution by using water baths or other sources of external heat, like a microwave oven, direct sunlight, or a radiator.• After thawing, check the bag for any leaks by squeezing it gently.• Thawed solution bags should not be re-frozen.• Thawed solution bags should be used within 24 hours after removal from the freezer.• Once the solution has thawed, it must then be placed in the refrigerator until it is ready to be used.

DO NOT USE THE BAG/ECLIPSE IF:

• Any leaks are present.• There is any cloudiness that does not disappear with gentle mixing of the solution.• Any particles or specks appear in the solution.• The label on the bag/Eclipse does not have your name on it.• The label on the bag/Eclipse has a different drug or dose listed.• The expiration date on the label has passed.


Review of Instructions by NursePatient Copy

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Flushing with Sodium Chloride and Heparin is often needed if medications are to be separated from each other. This is often done by using the “SASH” method.

Clean Technique • Wash your hands and prepare a clean and dry surface to work on. • Do not have any animals, including cats and dogs, in working area. • Prepare your supplies, such as gathering flushes and medications. • Clean catheter end cap with alcohol. • Attach medication tubing to clean catheter end cap, taking special care to protect both from dirty surfaces. • Dispose of waste appropriately.

Signs and Symptoms to Report to MD / Nurse / Pharmacist • Redness, swelling, pain, drainage or unusual lines near catheter insertion site . • Dressing wet, soiled, or coming off. • Nausea, vomiting, diarrhea, constipation. • Fever, chills, rash.

Storage of MedicationsUnless instructed otherwise, all medications are stored in the refrigerator. Remove for administration 1 – 12 hours prior to dosing, as indicated on the medication label.

Additional Questions Regarding medications and/or side effects, should be directed the pharmacist at 907.565.6100. You may also refer to the provided information in your Geneva Woods Pharmacy, Inc. Patient Information Packet.

S

A

S

H

SALINE (SODIUM CHLORIDE) (WHITE CAP ON SYRINGE)

ADMINISTER MEDICATION

SALINE (SODIUM CHLORIDE) (WHITE CAP ON SYRINGE)

HEPARIN (YELLOW OR BLUE CAP ON SYRINGE)


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IV Therapy Patient EducationGeneva Woods Pharmacy Copy

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q Instruction given to patient: _______________________________________________________________

q Instruction given to caregiver: _____________________________________________________________

Type of intravenous therapy and pump used: ____________________________________________________

I have been instructed in and have demonstrated to my nurse:(Please check all those that apply)

Caring for my intravenous catheter and site care:

q Flushing with normal saline and heparin q Clean Technique

q Signs and symptoms to report to MD/nurse

Giving my own intravenous medication:

q Storing medication properly q Preparation of work area

q Ordering equipment and/or supplies q Disposing of medication safely

q Maintaining clean technique CADD Pump functions: (if applicable)

q Resetting the reservoir volume q Changing the bag

q Operating the Stop/Start button q Alarm procedure

q Changing the battery q Operating the Dose button (if applicable)

Identifying potential complications:

q of the intravenous pump q of the medication

q of the catheter (including site insertion Recognizing when and who to notify in case of complications and/or questions:

Physician: ___________________________________________________ Phone: _____________________

Nurse: ______________________________________________________ Phone: _____________________

After-Hours Contact 907.565.6100 I understand that I am responsible for the administration of my own intravenous therapy and for contacting my physician or nursing as problems arise. I have also been informed of the risks if I fail to administer intravenous therapy according to my physician’s or nurse’s instructions.

______________________________________________________________ ___________________________________________Signature of Patient/Representative Representative’s Printed Name

______________________________________________________________ ___________________________________________Date Relationship to patient AND reason patient cannot sign. NOT AVAILABLE / INCAPACITATED / PHYSICAL LIMITATION / POA

______________________________________________________________ ___________________________________________Nurse’s Signature Date


Authorization of Service/Care, Rental/Sales Terms, and Assignment of Benefits

This agreement is binding as long as I am receiving equipment, products, or services from Geneva Woods Pharmacy, Inc. The word “CLIENT” is understood to be the person receiving medical equipment and/or supplies from Geneva Woods Pharmacy, Inc.

Please acknowledge each section with your initials.

1. _______ AUTHORIZATION OF SERVICE/CARE: a) The client understands that their signature on the acknowledgement form of this agreement authorizes Geneva Woods Pharmacy, Inc. (GWP) to provide the products and/or services to them. The client also understand that the products and/or services provided to them by GWP, or its employees, are provided under the direction of their physician and that GWP is not liable for any act, injury, damage, or omission when following the instructions of their physician.b) Home Infusion Only: The client has been advised of and understands the benefits and risks of home drug therapy. The client further understand that any complications, injuries, or adverse results cannot be given the immediate medical attention in the home as in the hospital setting. The client also understands that in any drug therapy there are risks that are known as well as unknown. The client has discussed these matters with their physician and have indicated their willingness to undergo home drug therapy. The client hereby consents to receive the home care services provided by GWP.c) GWP maintains twenty-four (24) hour availability by telephone. Qualified staff is always available to assist with equipment malfunction, or other related emergencies. Forty-eight hour advance notice is essential for routing weekday delivery and services.

2. _______ RENTAL/SALES TERMS:a) The client understands that equipment rented under this agreement remains the property of GWP. The client agrees not to assign possession rights of the rental equipment. Title to the equipment does not transfer to them until equipment is purchased and paid for in full. The client agrees to return the equipment in the same condition, as it was when received, normal wear and tear excluded. Rental charges will continue until equipment is picked up or returned to GWP.b) The client understands that they will be charged for the full retail amount of any rental equipment that fails to be returned, is lost or damaged resulting from negligence, theft, fire, abuse, accident, or any other cause other than reasonable wear.c) GWP shall replace or repair defective equipment in a timely manner. GWP shall not be responsible for incidental or consequential damage due to clients’ failure to timely notify GWP of any malfunction/defect or any unauthorized modifications made to rental equipment.d) The client understands that they will return rental equipment when there is no longer a medically necessity for it.e) The client agrees to notify GWP if they move, enter a nursing facility of any kind, enter a hospital, or become a hospice patient. The client understands that Medicare Part “B” does not cover rental of this equipment while the patient is in a nursing facility. The client will call GWP or write to the corporate office address in the event of these occurrences.f) The client agrees to not move any equipment without prior permission from the company.g) GWP honors all warranties expressed and implied under applicable state law. GWP will not charge for the repair or replacement of Medicare covered items/services covered under warranty.h) GWP advises Medicare beneficiaries that they may either rent or purchase inexpensive or routinely purchased durable medical equipment (DME). Inexpensive DME is defined as equipment whose purchase price does not exceed $150.00. Other routinely purchased DME consist of equipment that is purchased at least 75 % of the time.i) Sales returns will be accepted in unopened packages and/or saleable condition within thirty (30) days from date of original invoice with proof of purchase. No merchandise will be accepted for return if worn next to the skin, used for sanitary or hygienic purposes or if it is disposable (i.e. oxygen, underpads or diapers, lancets, enterals, compression garments, creams, sprays, gels, etc). Special order items may require a deposit and are non-returnable.

3. _______ ASSIGNMENT OF INSURANCE BENEFITS: a) The client authorizes direct payment to GWP of any insurance benefits otherwise payable to them for products or services provided by GWP any of its subsidiaries or agents.b) The client also authorizes their insurance company, including Medicare and Medicaid, to provide to any employee of GWP any and all information regarding to their insurance benefits and status of claims submitted by GWP for services rendered.c) This authorization is in effect until the patient chooses to revoke it in writing.

___________________________________________________________________________________________________________Client Name

______________________________________________________________ ___________________________________________Signature of Client or Client’s Legal Representative Date

______________________________________________________________ ___________________________________________Printed Name of Client’s Legal Representative Relationship to Client

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Acknowledgement of My Financial Responsibility

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The client understands that their insurance coverage may not pay the total cost of the medication, equipment, products, or services provided by Geneva Woods Pharmacy, Inc. and/or its subsidiaries (GWP). The client acknowledges their obligation to pay the balance between what their insurance coverage will pay and what GWP charges for medications, equipment, products, or services. The client further acknowledges that they will be responsible to pay, within 60 days from the date the claim was submitted to their insurance, the full amount of charges associated with any medications, equipment, products, or services they receive from GWP, should their insurance deny payment for any reason, including, but not limited to; the clients failure to qualify for any medications, products, or services; non-coverage by their insurance payer; or the clients failure to provide complete and accurate information to GWP necessary for billing their insurance payer. GWP shall have the right to pick up all equipment if financial responsibilities are not met. The client authorizes GWP to initiate a complaint to the Insurance Commissioner on their behalf. The client agrees to remit to GWP any payments made directly to them by their insurance payer for medications or products provided by GWP. The client agrees to be responsible for their co-payment and/or annual deductible amounts. Statements are mailed monthly with payment due by the end of each month. Payments can be mailed or taken over the phone by our Accounts Receivable Department. We accept cash, personal checks, company checks, money orders, and credit cards (VISA, MasterCard, American Express, and Discover Card). We also make credit card pre-payment arrangements for anticipated monthly client balances. Beginning on the 61st day after billing, a $30.00 late fee may be added to the balance every month until the balance is paid in full. GWP will be entitled to the full amount due on the account, including, but not limited to, attorney fees and/or collection fees that may accrue. Also, in the case of default, the client authorizes GWP to attach all rights to their Alaska State Permanent Fund Dividend until all financial obligations are met (where applicable).

___________________________________________________________________________________________________________Client Name

______________________________________________________________ ___________________________________________Signature of Client or Client’s Legal Representative Date

______________________________________________________________ ___________________________________________Printed Name of Client’s Legal Representative Relationship to Client

This agreement is binding as long as I am receiving medication, equipment, products, or services FROM Geneva Woods

Pharmacy, Inc. and/or its subsidiaries. The word “client” is understood to be the person receiving medication, medical

equipment, and/or supplies FROM Geneva Woods Pharmacy, Inc. and/or its subsidiaries.


Home Infusion Patient Acknowledgement Form

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Client Name: _____________________________________________________________________________(Please Print)

______________________________________________________________ _______________________Signature of patient or patient’s representative Date

______________________________________________________________ _______________________Printed name of patient’s representative Relationship to patient

______________________________________________________________ _______________________Signature of GWP representative Date

I have received, read, and understand the above referenced materials from Geneva Woods Pharmacy Inc. and will abide by all terms and authorizations within.

Patient Intake Pamphlet contains the following:

• Client Emergency Preparedness Sheet

• Notice of Privacy Practices

• Client Bill of Rights and Responsibilities

• Medicare Supplier Standards

• Client Infection Control

Advanced Beneficiary Notice (Only if required)

Plan of Care Discussed with Client

Coverage & Benefits Form Discussed with Client (if applicable)

Patient Intake Packet which contains the following:

• Blood and Body Fluid Precautions

• Storage and Handling of Solutions

• Sharps Container Guidelines

• Review of Instructions by Nurse

• IV Therapy Patient Education Form

• Financial Responsibility Notice

Authorization of Service/Care & Assignment of Benefits

Therapy Delivery System Education Sheet

Check All That Apply


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