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EXTENDED PERSONAL CARE SERVICE PROVIDER AGREEMENT NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES MEDICAL SERVICES DIVISION/HOME AND COMMUNITY BASED SERVICES Clear Fields SON 576 (122014) Printed Name Provider

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How to fill out extended personal care service

How to fill out extended personal care service?

01

Start by gathering all the necessary information. This includes the name and contact details of the person who needs the extended personal care service, as well as their medical history and any relevant documents.

02

Fill out the personal details section. This usually includes the person's full name, date of birth, address, phone number, and emergency contact information.

03

Next, provide information about the specific care needs. This may involve describing any medical conditions, disabilities, or limitations that require attention. Be as detailed as possible so that the care provider can understand the individual's needs and provide appropriate support.

04

Indicate the desired start date and duration of the extended personal care service. Specify whether it is for a short-term period or if it is an ongoing arrangement.

05

Consider any additional services or accommodations that may be needed. This could include assistance with medication management, transportation, meal preparation, or specific equipment requirements.

06

Provide any preferences or specific requests regarding the caregiver. For example, if the person needing care has a preference for a male or female caregiver, or if they have any language or cultural preferences.

07

If there are any specific instructions or guidelines for the caregiver, such as dietary restrictions, medication schedules, or physical therapy routines, make sure to include them in the form.

Who needs extended personal care service?

01

Individuals with chronic illnesses or disabilities that require ongoing assistance and support.

02

Elderly individuals who are unable to perform certain activities of daily living independently, such as bathing, dressing, or grooming.

03

Individuals recovering from surgery, injury, or illness who need extra help during the recovery period.

04

People with cognitive impairments or mental health conditions that limit their ability to care for themselves.

05

Family members or caregivers who are unable to provide the necessary level of care and need additional support.

Overall, extended personal care service is designed for anyone who requires personalized assistance with their daily activities and healthcare needs.

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What is extended personal care service?

Extended personal care service refers to services provided to individuals who require assistance with activities of daily living, such as bathing, dressing, and meal preparation, for an extended period of time.

Who is required to file extended personal care service?

Providers of extended personal care services are required to file the necessary documentation with the relevant authorities.

How to fill out extended personal care service?

Extended personal care service forms can be filled out online or submitted in person to the appropriate agency. Providers must include detailed information about the services provided and the individuals receiving care.

What is the purpose of extended personal care service?

The purpose of extended personal care service is to ensure that individuals who require assistance with activities of daily living receive the necessary support and care.

What information must be reported on extended personal care service?

Providers must report details such as the type of services provided, the duration of care, and the individuals receiving care.

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