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Getting Started with Private Duty Booklets

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Agency Name*
As it should appear throughout the book
Name*
First Last
Title
Email*
Agency Address(es)*
Type in the addresses associated with your Agency. Enter N/A if uploading an agency address list file
Agency Address(s) File
If uploading a file with all agency addresses and phone numbers, please enter N/A in the next two fields
Max. file size: 50 MB.
What's your agency's billing address?*
- The same as provided above.
- No, I'll provide another address.
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Agency Phone Number(s)*
Enter N/A if you uploaded an agency address list
Office Hours - Open*

: Hours

Minutes

AM/PM
Office Hours - Close*

: Hours

Minutes

AM/PM
Welcome Letter
Optional - If none provided we will use the Medforms generic welcome letter
Max. file size: 50 MB.
Agency Ownership

Do you need to meet the Federal Conditions of Participation?*
- Yes
- No
Which state department regulates your license (i.e., Department of Health, Dept of Social Services, etc.)*
*Important: Refer to licensure category on your license.*
Do you have a Texas location(s)?*
- Yes
- No
Use MedForm's Generic Drug testing Policy*
- Yes
- No
Drug testing Policy File*
Max. file size: 50 MB.
Use MedForm's Generic A&E Policy*
- Yes
- No
Agency A&E Policy File*
Max. file size: 50 MB.
After Hours Phone Number*
Verify Services Provided*
- Personal Care
- Homemaker Services
- Companion Services
- Other
Other Services
Accepted Payment Sources*
- Medicaid
- Medicaid Waiver Programs
- Private Insurance
- Private Pay
- Other
Name of Medicaid Waiver Program (for example: CHOICES, STAR PLUS)
Other Payment Sources Accepted
Verify Staff Members perform quarterly client health assessments*
- Yes
- No
Supervision of Personal Care Aides required?*
- Yes
- No
If yes, frequency of supervision:
Provide details on Staff Member health assessment policy*
Please verify or attach your Agency policy if different than shown in 'Charges'*
- Verified
- Use Agency Policy
Hidden
Agency Charges Policy*
Max. file size: 50 MB.
HH-CAHPS Vendor Name, if you have one*
Home Health Care Consumer Assessment of Health Care Providers Systems (HHCAHPS). Put N/A if no vendor. If you do not have an HH-CAHPS Vendor, you are classified as a startup and subject to our startup package pricing.
Please verify staff title*
- CNA
- Personal Care Aide
- Home Health Aide
- Other:
Hidden
Other:*

A CNA can or cannot:
Bathe you*
- Yes
- No
Shampoo and comb your hair*
- Yes
- No
Clean and file your nails*
- Yes
- No
Provide or assist you with oral care*
- Yes
- No
Provide skin care*
- Yes
- No
Check your temperature, pulse and respiration*
- Yes
- No
Help you walk*
- Yes
- No
Transfer you from your bed to a chair*
- Yes
- No
Assist you with toileting*
- Yes
- No
Position you in bed*
- Yes
- No
Prepare meals*
- Yes
- No
Feed or assist you in feeding yourself*
- Yes
- No
Provide exercises during care*
- Yes
- No
Change your linens*
- Yes
- No
Tidy up your immediate surroundings*
- Yes
- No
Sit with you when family is or is not present*
- Yes
- No
Take the place of a licensed nurse*
- Yes
- No
Give an enema*
- Yes
- No
Cut your fingernails or toenails*
- Yes
- No
Apply heat of any kind*
- Yes
- No
Assist with feeding tubes*
- Yes
- No
Prepare or administer medications*
- Yes
- No
Interpret medical information*
- Yes
- No
Purchase/transport any form of medication*
- Yes
- No
Transport anyone in their cars*
- Yes
- No
Do banking or assist with writing checks*
- Yes
- No
Open mail*
- Yes
- No
Perform heavy housework (cleaning windows, washing curtains, move heavy furniture, clean entire house)*
- Yes
- No
Assist in the preparation of or witness any Advance Directive or will*
- Yes
- No
Please verify hiring of Agency employee policy*
- Verified
- Not verified. I will provide my own:
Hidden
Hiring of Agency employee Policy*
Max. file size: 50 MB.

Homemaker Services may include:
Cleaning
- Vacuuming and sweeping
- Surface dusting
- Mopping
- Removing trash
- Washing dishes or loading/unloading dish washer
- Cleaning kitchen appliances (refrigerator, stove)
Laundry
- Washing laundry at home or at a laundromat. Only the client's clothing and linens are washed. You must furnish all cleaning supplies (soap, bleach, etc.).
Meal Preparation
- Preparing light meals such as soups, sandwiches, microwavable meals, etc.
Errands
- Arranging or accompanying to doctor/clinic appointments if time does not exceed allotted time
- Limited shopping for groceries
- Picking up commodities
NOTE: Emergency transportation must be provided by ambulance.

Problem Solving Procedure Administrator*
First Last
Problem Solving Procedure Contact Address*
- Same as Agency Address
- Other
Problem Solving Procedure Contact Address (Other)*
Street Address Address Line 2 City State ZIP Code
Problem Solving Procedure Contact Phone*
Additional Complaint Contact
Accredited?*
- Accredited by Joint Commission
- Seeking accreditation by Joint Commission
- Accredited by CHAP
- Seeking accreditation by CHAP
- Accredited by ACHC
- Seeking accreditation by ACHC
- None

Notice of Privacy Practices*
- Use MedForms' Generic HIPAA Notice
- Use Agency's HIPAA Notice (enter or attach file below)
Privacy Practice Details*
If using MedForms Privacy Practice - Name/Title of Contact person, Agency Name, Address, Phone
Privacy Policy File*
If using your own
Max. file size: 50 MB.
Please verify Hiring Prohibition or attach agency policy*
- Verified
- Use Agency Policy
Agency Hiring Prohibition Policy*
Max. file size: 50 MB.
Agency Policy on Advance Directives*
If using ours, be sure to update your P/P with our version
- Use MedForms Version
- Use your own
Advanced Directives File*
If you are using your own
Max. file size: 50 MB.
Emergency Preparedness Plan Guidelines*
- Level I – Within 24 hours; Level II – Within 24-48 hours; Level III – Within 48-72 hours
- Other (please attach)
Emergency Preparedness Plan Guidelines File*
If using your own
Max. file size: 50 MB.
Inclement Weather/Disaster Sections*
- Flood
- Landslide
- Tornado
- Hot Weather
- Winter Storm
- Hurricane
- Earthquake
- Wildfire
- Civil Disturbance
- Biological Threat
- Emerging Infectious Diseases
- Chemical Exposure
- Explosion
- Nuclear Explosion
- Nuclear Power Plant Emergency
- Emergency Preparedness and Pets
Include Child Safety Section*
- Yes
- No

Forms
Client Service Agreement
- Single-Part form
- Two-Part NCR form (patient signature bleeds to second page, upcharge)
Verify Client Service Agreement items to include
- Medicaid
- Non-Medicare/Medicaid/Governmental Agencies
- Private Insurance/Assignment of Insurance Benefits
- Self Pay/Co-Payments/Deposits/Late Charges/Overtime
- Service Interruption
- Termination
Other Forms to Include
- Home Health Aide/Homemaker Assignment/Care Plan
- Private Duty Physical Assessment
- Physical Assessment
- Home Health Aide Chore Check List
- Prescription and Non-Prescription Medications
Additional Forms to include in the book
Drop files here or

Max. file size: 50 MB.

Agency Logo
Please upload your logo in vector file format (.eps or .ai). This is the only file type that allows us to your print your logo clearly on your cover.
Drop files here or

Max. file size: 50 MB.
Additional Comments or Instructions
Is this booklet affiliated with an agency that already has a booklet with us? If so, what agency and booklet? This helps us ensure consistency.
Expected first order Quantity*
We strongly recommend orrdering a six month supply based on your current patient admissions.
- 50-149 booklets
- 150-499 booklets
- 500-4999 booklets
- 5000+ booklets
One-time Setup Fee
Please pay the one-time setup fee via check made payable to MedForms (mail to MedForms, P.O. Box 40333, Nashville, TN 37204) or call 615-386-6320 ext. 301 to pay via credit card (Visa, MC, or Discover). Your setup fee amount is based on your first order quantity.
Interested in learning more about our other booklets?
- Home Health
- Hospice
- HME
- Infusion
- Disease Education (Arthritis, CHF, COPD, Stroke, Wound Care)

Contact

P.O. Box 3001
Brentwood, TN 37024

1-800-843-9178

Monday - Friday
8:00am - 4:30pm CST

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