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.