Free Form 02AG032E (AG-7) Instructions - Oklahoma

Personal Care Provider Communication Purpose of form

02AG032I (AG-7)

Form 02AG032E is a communication tool used by service agencies to notify the OKDHS nurse of requests for change in the client's service plan. The OKDHS nurse also uses this form as justification for a service plan addendum. Instructions

A. Identifying information. Self-explanatory. B. Provider changes recommended. Check an appropriate change code for
each service unit requiring change. Under justification, enter a specific comment regarding why the change is needed. Indicate the date each service changed, such as date of hospitalization, or date services should be resumed. Justification. This section is used when there is a change requested or there is no change in the service unit but there is information from the OKDHS nurse concerning the client. For example, the client is requesting a specific person not be assigned as his or her aide.

C. OKDHS nurse recommendation. OKDHS nurse checks the appropriate box. If
service is terminated, enter the reason in the comment section and an effective date. If service is increased, enter the number of units. If service is decreased, the client's worker provides the effective date for advance notice of negative action. Comments. OKDHS nurse enters any specific information regarding the decision. OKDHS nurse may approve the request if there will NOT be any change in the cost of the service, number of units, or type of service. For example, the OKDHS nurse approves the client's request not to have a specific aide return to give care. If an interdisciplinary team (IDT) meeting is requested, list reasons under comments. This may be requested in tandem with a change in services. Include the date and time of the meeting on the form. Write recommendations resulting from the IDT meeting under OKDHS nurse recommendations.

D. OKDHS area nurse. Form 02AG032E is sent to the OKDHS area nurse for
approval or denial, with effective date, and returned to OKDHS nurse.

Signature(s).
Section B is signed by the person or agency making the request and his or her title and date of request are completed. Section C is signed by the OKDHS nurse, dated, and phone and fax numbers completed. Section D is signed and dated by the OKDHS area nurse. Routing Original - client file Copy - service provider

OKDHS issued 11-10-2006

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