Patient Acknowledgement Form

Please review each statement carefully and check the box to confirm your understanding before signing.

This acknowledgement form confirms that you have been informed of and understand the terms of care provided by Zee's Healthcare LLC. Please read each statement and check the box to confirm. All fields marked * are required.

Patient & Signatory Information

Patient / Client Name *

Your Relationship to Patient *

Your Full Name (Signatory) *

Email Address *

Phone Number

Date *

Acknowledgement Statements

Please check each box to confirm you have read and understood each statement.

I understand that Zee's Healthcare LLC provides skilled home nursing services and that all care is delivered under the direction of a licensed physician.

I acknowledge that I have been informed of the plan of care, including the services to be provided, the frequency of visits, and the goals of treatment.

I understand my right to participate in planning my care and to be informed of any changes to the plan of care.

I acknowledge that I have been informed of my rights as a patient/client, including the right to refuse treatment.

I understand that Zee's Healthcare LLC will maintain the confidentiality of my health information in accordance with HIPAA regulations.

I acknowledge receipt of the Notice of Privacy Practices and the Patient Rights and Responsibilities document.

I authorize Zee's Healthcare LLC to communicate with my designated emergency contact and healthcare providers as necessary for my care.

I understand that I may contact Zee's Healthcare LLC at 224-277-1645 with any questions, concerns, or complaints regarding my care.

Please check all boxes above before submitting.

Questions? Call us at 224-277-1645