subject_line
Contact and Authorization Log
To finish the setup of this form, go to Form->Notifications to setup your email notification.
For the "To" option enter your email address and for the "From" option choose the email item on the form.
Lastly, delete this item.
Consumer Name
*
Email Address
*
Nurse's Name
*
Title
*
RN
LPN
Off. ManagerAdm./GM
Action
*
Physician Contact
Request to Contact Physician
Consumer Follow-Up
Consumer Contact
Review of Verbal Orders
Medicaton List Updated
Pre-authorization Request
Service Change
CM Contact
Legally Authorized/Surrogate Decision Maker
Updated Care Plan
DME Requests / Rx for DME
Reason contacting physician
*
Obtained verbal orders (New Services)
Obtained verbal orders (Recertification)
Reported consumer status
Report a notice of hospitalization
Obtained guidance
Patient D/C Notification
Reason contacting consumer
*
HHABN - Service Change
Regarding an incident
Notification of a change
Other
Consumer Change
*
Insurance change
Address change
Phone number change
Physician change
Schedule Change
Other
New Insurance Name
*
New HICN
*
Effective Date
*
+
New Address
*
Apt #/Suite #
*
New Zip
*
Date of Contact
*
+
Date of Change
*
+
Time of Contact
*
A.M./P.M.
*
A
P
Confirmation/Ref. #
*
Verbal Orders obtained (specific and detailed)
*
HHA
SN
PT
OT
Other
Written Documentation Provided
*
Request to fax information
Faxed Information
# of HHA Hours
*
Frequency
*
Up to 1 x Daily
Up to 2 x Daily
Up to 1 X Weekly
Up to 2 X Weekly
Up to 3 X Weekly
Up to 4 X Weekly
Other
HHA Duration
*
Updates Made to Care Plan
*
Medication
Service Frequency
Tasks Performed
Duration of Services
Medication Review Ref.#
*
Physician Contact Ref.#
*
# of SN Hours
*
Frequency
*
Up to 1 x Daily
Up to 2 x Daily
Up to 1 X Weekly
Up to 2 X Weekly
Up to 3 X Weekly
Up to 4 X Weekly
Other
SN Duration
*
Incident Ref.#
*
Add Notes Regarding Services
*
Add
Consumer status reporting:
*
Abuse (suspected)
Death
Fall
Hospitalization
Infection
New medication prescribed by secondary or other physician
Significant Change In Condition
Unexpected Crisis - indirectly affecting health
Vitals outside of normal range
Other
Details Regarding Nature of Physician Contact
*
Instructions Obtained
*
Physician's Response and/or Instructions
*
Additional Notes Regarding Services
*
Specify Other
*
D/C Date
*
+
Date Dr. Notified
*
+
Reason for discharge
*
Patient goals met
Maximum capacity reached
Other
Notified D/C Summary Available Upon Request
*
Yes
Other (reason for discharge)
*
Details of Consumer Contact
*
Details of Contact
*
Documentation
*
Request office to send information
Documentation of consumer contact within email.
Consumer F/U due to an incident?
*
Yes
No
Consumer Satisfied with Resolution
*
Yes
No
Specify Service Change
*
HHA - Change in Hrs.
SN - Change in Hrs.
Review of Verbal Orders
*
I have originated the orders being sent to the identified physician.
I hereby authorize documented orders as obtained verbally to be sent on my behalf.
I confirm the documented orders reflect the directives provided and/or authorized over the phone.
Date of Review
*
+
Initialing Authorization
*
Physician's Office Order's Obtained:
*
Office Contact's Name
*
Physician Contacted Verbal Orders Reference #:
*
Med. List Updates Completed (Confirmed):
*
In Office
In the home
Date of Med. List Update
*