Client Supply Authorization Request Form (1)

Client Supply Request Form

Phone: (248) 395-3777, Fax: (248) 395-3370, www.hchs.com, 28000 Woodward Ave., Ste 100., Royal Oak, MI 48067

Client Last Name: *

Client First Name: *

This request is: *

For a new client

For an existing client, with an existing order

For an existing client, with a new order

The client listed above will require items to be supplied by HealthCall:

Yes

No

If no items are required, please scroll to the bottom of the page and sign. You do not need to fill out the rest of the form.

If items are required, please complete the rest of the form, indicating which items are needed. Those not needed should remain NA.

If your client requires Contact Precautions, please make sure to indicate an Infection Control Kit is needed.

Does the client have a supports coordinator or external case manager?

Yes

No

If the client has a supports coordinator or external case manager, have you attempted to contact them regarding the client's supply needs?

Yes

No

What was the outcome of that contact?

If necessary, please provide the contact information for the supports coordinator or external case manager.

The client will need the following items in the home:

Adult Briefs:

If other, note size needed:

Bathroom Tissue:

Blue Pads:

Disinfecting Wipes (general):

Disinfecting Wipes (for C-Diff):

See Infection Control Policy & Procedure

Dish Soap:

Gloves:

For multiple sizes, please list sizes needed in the comments

Hand Sanitizer (Large Pump):

Hand Soap (gallon):

Laundry Detergent:

Paper Gowns:

Paper Masks:

Paper Towel (case):

Syringes:

If syringes are needed, specify size and type:

Starter Kit:

Starter Kit Includes - Hand Sanitizer (Large Pump), Hand Soap (gallon + filled pump dispenser), and Paper Towel (case; 12-22 rolls)

Infection Control Kit:

General Infection Control Kit Includes - Disinfecting Wipes, Gloves, Hand Sanitizer (Large Pump), Masks

(If gowns are needed, please list below)

Contact Precuations Infection Control Kit Includes - Disinfecting Wipes (C-Diff), Gloves, Hand Soap, Masks with Eye Shield, Paper Gowns with Cuffed Sleeves

Other Supplies Needed (enter as numbered list):

Client Street Address:

Client City:

Client State:

Client Zip Code:

Residence Type:

Effective Date: +

Delivery Method:

Clinical Supervisor

Courier

Direct Ship to Client (Preferred Method When Suitable)

Pickup (from HealthCall office)

I have completed a Start Stop Courier Request Form:

Yes

No

If multiple delivery methods are selected, please note which items should be delivered by which method (If only one delivery method is selected, type NA in the box below):

Additional Comments: 🛈

Clinical Supervisor: *

Date: * +

v3 - 02.01.2020