Free Home Health Agency Contract Review Worksheet-F-62657 - Wisconsin



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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62657 (Rev. 07/08) STATE OF WISCONSIN HOME HEALTH AGENCY CONTRACT REVIEW WORKSHEET (OPTIONAL) Name Agency License Number Name Surveyor (s) Date Worksheet Completed 133.19(1)(a) Name of Contracted Providers A statement that patients are accepted for care by the primary home health agency. 133.19(1)(b) 133.19(1)(c) Agreement to conform to all applicable agency policies, including personnel qualifications. 133.19(1)(d) 133.19(1)(e) 133.19(1)(f) A list of services to be provided. A statement concerning A statement about the Procedures for submitting the manner in which contractor's responsibility clinical and progress services will be controlled, for participation in notes, scheduling visits, coordinated, and developing plans of and undertaking periodic evaluated by the

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DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62657 (Rev. 07/08)

STATE OF WISCONSIN

HOME HEALTH AGENCY CONTRACT REVIEW WORKSHEET (OPTIONAL)
Name Agency License Number

Name Surveyor (s)

Date Worksheet Completed

133.19(1)(a) Name of Contracted Providers
A statement that patients are accepted for care by the primary home health agency.

133.19(1)(b)

133.19(1)(c)
Agreement to conform to all applicable agency policies, including personnel qualifications.

133.19(1)(d)

133.19(1)(e)

133.19(1)(f)

A list of services to be provided.

A statement concerning A statement about the Procedures for submitting the manner in which contractor's responsibility clinical and progress services will be controlled, for participation in notes, scheduling visits, coordinated, and developing plans of and undertaking periodic evaluated by the primary treatment. patient evaluation. agency.

File Size: 11.6 kB
Pages: 1
Date: April 27, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 126 Words, 903 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f6/f62657.pdf