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PERSONAL CARE SERVICES PROGRAM DISCONTINUATION OF SERVICES INSTRUCTIONS Form Name: Personal Care Request for Discontinuation of Services (Policy Section 517.28) Purpose: To request discontinuation
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First, gather all the necessary personal information such as name, address, date of birth, and contact details.
02
Start by filling out the basic information section of the form, including your name, address, and phone number.
03
Next, provide details about your medical history, including any existing conditions or medications you are currently taking.
04
If applicable, fill out the section related to your insurance coverage or Medicaid eligibility.
05
Specify the type of personal care services you require, such as assistance with bathing, dressing, or meal preparation.
06
If you have any specific preferences or instructions for the caregiver, make sure to include them in the designated section.
07
Sign and date the form to complete the process.
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Review the filled-out form for accuracy and make any necessary corrections before submitting it.

Who needs personal care services forms?

01
Individuals who require personal care services or assistance with daily living activities.
02
Those who have medical conditions or disabilities that prevent them from fully performing self-care tasks.
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Individuals who may need support due to age-related limitations or temporary injuries.
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People who are transitioning from a hospital or rehab facility to home and require assistance.
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Personal care services forms are documents used to report personal care services provided to individuals who require assistance with daily living activities.
Care providers or agencies that offer personal care services are required to file these forms.
To fill out personal care services forms, providers need to accurately document the services provided, the duration of services, and any relevant information about the recipient.
The purpose of personal care services forms is to monitor and track the care provided to individuals in need of assistance with daily living activities.
Information such as the date of service, type of care provided, duration of care, and any notes or observations about the recipient's condition must be reported on these forms.
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