Get the free Home and Community Care Referral Form HIS 759. form

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Reset Footprint Form Save Form___ ___ Last NameFirst Name Date of Birth: ___ Patient # ___ DD/MM/YYY Affix Label or Print HAN ___ Version Code ___Referral for Home and Community Care Services___*Relevant

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How to fill out home and community care

01

Ensure you have all necessary information such as medical history, current medications, and any specific care needs

02

Contact the home and community care provider to set up an initial assessment

03

During the assessment, provide accurate information about your needs and preferences

04

Work with the provider to develop a care plan that meets your needs and goals

05

Review and update the care plan regularly to ensure it continues to meet your needs

Who needs home and community care?

01

Individuals who have difficulty with daily tasks such as bathing, dressing, and meal preparation

02

Individuals who require assistance with medication management

03

Individuals who need support to remain living independently in their own homes

04

Individuals recovering from surgery or illness who need temporary assistance

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What is home and community care?

Home and community care refers to services that support individuals to live independently in their homes and communities, such as personal care, meal preparation, and transportation.

Who is required to file home and community care?

Individuals who are in need of home and community care services are required to file for them.

How to fill out home and community care?

To fill out home and community care, individuals can contact their local health department or social services agency for assistance.

What is the purpose of home and community care?

The purpose of home and community care is to help individuals maintain their independence and quality of life while receiving necessary support services.

What information must be reported on home and community care?

Information such as the type of services received, frequency of visits, and any changes in the individual's condition must be reported on home and community care.

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