Staffing Patients Paperwork

Page 1

Staffing Patients Paperwork Guide

Note: Please utilize RNs only on these visits
Staffing Company / IV Company Paperwork Requirement / 3HC Paperwork Required Initial Visit / 3HC Paperwork Required Subsequent Visits / Comments
Coram / Complete Coram’s consent form. Send original to Coram in self-addressed, stamped envelope 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 copy to Coram.
  • Request SN Notes within 7 Days
/
  • Routine V5 Visit Form
  • IV Therapy Visit Report
  • Medication Profile
  • Discharge Summary
/
  • Include vital signs on all SN visits.
  • Coram will reimburse 3HC forVancomycin Peak Visit
  • There should not be any change in the POC without first notifying the Clinical Coordinator at Coram (800) 245-2463.

Accredo / Complete Accredo’s Consent form. Send original to Accredoin self-addressed, stamped envelope within 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 copy to Accredo.
/
  • 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.

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. /
  • 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.
/
  • 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) 599-9339.

UNC Health Care Specialists / Complete UNC Health Care Specialists’ consent form. Send original to UNC Health Care Specialists in self-addressed, stamped envelope immediately. /
  • 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.
/
  • 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.

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
/
  • 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) 948-6606.
  • 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.

Curascript / Complete Curascript’s consent form. Fax or mail to Curascript’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.
/
  • 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 Curascript (877) 298-6186.

Hemophilia Health Services / Complete Hemophilia Health Services consent form. Fax or mail to Hemophilia Health Services’ 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 Hemophilia Health Services.
/
  • 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 CareMark.
/
  • 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. (800-225-5967)

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. /
  • 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.
/
  • 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)

Jabez Infusion / Complete Jabez consent form. Fax or mail to Jabez’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 Jabez.
/
  • 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

LibertyMedical Specialists / Complete Liberty’s consent form. Fax or mail to Liberty’s corporate office within 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 Liberty.
/
  • 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 CristaClewisClinical Coordinator at Liberty (910) 625-6665

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