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.
Title *
Action *
Reason contacting physician *
Reason contacting consumer *
Consumer Change *
A.M./P.M. *
Verbal Orders obtained (specific and detailed) *
Written Documentation Provided *
Updates Made to Care Plan *
Add Notes Regarding Services *
Consumer status reporting: *
Reason for discharge *
Notified D/C Summary Available Upon Request *
Documentation *
Consumer F/U due to an incident? *
Consumer Satisfied with Resolution *
Specify Service Change *
Review of Verbal Orders *
Med. List Updates Completed (Confirmed): *