Form Cms-36 U3 - Consent For Home Visit
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
CONSENT FOR HOME VISIT
BENEFICIARY NAME:
ADDRESS:
By this document, I hereby consent to have State/Federal health survey personnel conduct a home visit to
ensure that the Federal requirements are met and to assist in evaluating the effectiveness and quality of
home health services that I receive from the ________________________________________________.
(Name of Home Health Agency)
I understand that consent for this visit is voluntary and none of my rights to confidentiality or privacy are
waived by my consent. I have been told and I understand that refusal to consent to a home health visit will
have no effect on the level or nature of Medicare/Medicaid benefits to which I am entitled.
BENEFICIARY, OR REPRESENTATIVE OF THE BENEFICIARY, SIGNATURE:
DATE:
Form CMS-36 U3 (12-90)
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