Staffing Patients Paperwork Guide Note: Please utilize RNs only on these visits Staffing IV Company Paperwork Company Requirement 3HC Paperwork Required Initial Visit Coram Complete Coram’s consent form. Send original to Coram in self-addressed, stamped envelope within 48-72 hours of visit. Accredo Complete Accredo’s Consent form. Send original to Accredo in self-addressed, stamped envelope within 72 hours of visit. Duke Home Infusion Complete Duke’s consent form. Fax consent to Duke Home Infusion within 48 hours of admission, along with full assessment, vital signs and SN notes. Do not use PRN visit note form. UNC Health Care Specialists Complete UNC Health Care Specialists’ consent form. Send original to UNC Health Care Specialists in self-addressed, stamped envelope immediately. Document1 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485). Send to MD for signature and forward copy to Coram. Request SN Notes within 7 Days 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485). Send to MD for signature and forward copy to Accredo. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Do Not Use PRN Visit Form Infusion Therapy Template POT (485). Send to MD for signature and forward copy to Duke Infusion. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485). Send to MD for signature and forward copy to UNC Health Care Specialists. 3HC Paperwork Required Subsequent Visits Comments Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. Coram will reimburse 3HC for Vancomycin Peak Visit There should not be any change in the POC without first notifying the Clinical Coordinator at Coram (800) 245-2463. Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at Accredo (866) 239-6037. Routine V5 Visit Form Do Not Use PRN Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. Nurse admitting the patient should contact Duke Infusion within 48 hours of the initial visit to verify orders. The name and number of the Duke contact person is on the authorization form. There should not be any change in the POC without first notifying the Clinical Coordinator at Duke Infusion (800) 5999339. Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at UNC Health Care Specialists (800) 239-0462. Nurses should call and speak directly to the pharmacist (919-465-9300) to notify them where the specimen was dropped off. The pharmacist will call and follow-up on the lab results to avoid delays. 1/11/13 Staffing Patients Paperwork Page 2 Note: Please utilize RNs only on these visits Staffing IV Company Paperwork Company Requirement 3HC Paperwork Required Initial Visit 3HC Paperwork Required Subsequent Visits Comments Walgreens Complete Walgreens consent form. Fax to Walgreens within 72 hours of the initial visit. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485): Send to MD for signature and forward a copy to Walgreen’s. Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Curascript Complete Curascript’s consent form. Fax or mail to Curascript’s corporate office within 48-72 hours of visit. Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Hemophilia Health Services Complete Hemophilia Health Services consent form. Fax or mail to Hemophilia Health Services’ corporate office within 48-72 hours of visit. Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at Hemophilia Health Services. (336-854-3128) CareMark Complete CareMark consent form. Fax or mail to CareMark’s corporate office within 48-72 hours of visit. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485): Send to MD for signature and forward a copy to Curascript. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485): Send to MD for signature and forward a copy to Hemophilia Health Services. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485): Send to MD for signature and forward a copy to CareMark. Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at Walgreens (800) 9486606. Any event not consistent with the routine care or services provided to the patient or related to the safety of the patient shall be reported to the Clinical Coordinator within 24 hours. Walgreens will monitor all lab results. Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at Curascript (877) 2986186. Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at CareMark. (800-2255967) Document1 11/13/12 Staffing Patients Paperwork Page 3 Note: Please utilize RNs only on these visits Staffing IV Company Paperwork Company Requirement 3HC Paperwork Required Initial Visit Advanced Home Care Complete Advanced Home Care consent form. Fax or mail to Advanced Home Care’s corporate office within 48-72 hours of visit. Jabez Infusion Complete Jabez consent form. Fax or mail to Jabez’s corporate office within 48-72 hours of visit. Liberty Medical Specialists Complete Liberty’s consent form. Fax or mail to Liberty’s corporate office within 72 hours of visit. Document1 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485): Send to MD for signature and forward a copy to Advanced Home Care. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485): Send to MD for signature and forward a copy to Jabez. 3HC Admission Agreement High Risk Consent Medication Profile SN Comprehensive V3 Form Infusion Therapy Template POT (485): Send to MD for signature and forward a copy to Liberty. 3HC Paperwork Required Subsequent Visits Comments Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at Advanced Home Care. (800-878-8980) Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Clinical Coordinator at Jabez (800) 432-5114 Routine V5 Visit Form IV Therapy Visit Report Medication Profile Discharge Summary Include vital signs on all SN visits. There should not be any change in the POC without first notifying the Crista Clewis Clinical Coordinator at Liberty (910) 625-6665 11/13/12