Free Form 02AG031E (AG-6) - Oklahoma

*02AG031E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Personal Care (PC) Service Plan
Copy to: Provider Client Client name Street address Unique ID number City Area code Phone County State Date sent: Date sent: OKDHS File Date sent: Date sent: Case number Zip

County office

Services One unit is 15 minutes.
Type of service Personal care Provider Hours per week Units per week Duties or tasks See Form 02AG029E

Other services. Service Authorization Model (SAM).
Type of service Provider SAM visit Other: I accept the service plan: Yes Date Client signature Agency nurse/OKDHS nurse signature Service plan period (one year) Effective date End date No Area nurse/designee signature Witness signature Witness signature Certification period (up to 36 months) Effective date End date Visits Up to five per year Duties or tasks

Comments/concerns:

Revised 6-15-2009

02AG031E (AG-6)

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