Staffing Patients Paperwork Guide
Note: Please utilize RNs only on these visits
Staffing
IV Company Paperwork
Company
Requirement
3HC Paperwork Required Initial
Visit
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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.
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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.
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UNC Health Care
Specialists
Complete UNC Health Care
Specialists’ consent form. Send
original to UNC Health Care
Specialists in self-addressed,
stamped envelope
immediately.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Jabez Infusion
Complete Jabez consent form.
Fax or mail to Jabez’s
corporate office within 48-72
hours of visit.
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Liberty Medical
Specialists
Complete Liberty’s consent
form. Fax or mail to Liberty’s
corporate office within 72
hours of visit.
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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)
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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
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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