CMS-36 Consent for Home Visit

CMS-36 Consent for Home Visit

You’ll use the CMS-36 form to consent to allow State or Federal health survey personnel to visit your home to make sure the home health services you are receiving are up to par. By signing this form, you are waiving your confidentiality and privacy as they relate to this home visit.

What you’ll need:
• You name and address
• The name of your home health agency
• Your signature

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