File Updates for 2025

Updating my information!

*A Comprehensive review and medical form may be required, for example if there are seizures we will need a seizure action plan. Please make sure we have all relevant information to provide care in a safe and comprehensive manner.
Objective: Friendly and professional reminder of all your rights and file update to make sure we have the most up to date information.
Client Information
CLIENT NAME (PERSON RECEIVING THE SERVICE), first and last*
Best Contact Person
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Communication*

Communication via text messages or other similar platforms such as social media, are not HIPAA compliant. I understand that if I choose to use these methods of communication, I am waiving my right to HIPAA in those instances. At anytime I can change my mind about communication methods and let Angels know how to communicate with me.
Phone Number*

Area CodePhone Number
Date of Birth*
Case Manager Information*

Yes or No ? (The state looks for this information when they come to visit us so we want to make sure we have it when they come)*

Rows	Yes	No
Do you have advanced directives? *If you don't know what this is the answer is no
Do you have a occupational therapist?
Do you have speech therapist?
I understand that I need email angelsservicellc@gmail.com to make any updates or to request copies of policies, etc.
I know and understand my rights and that my orginal intake as complete information as this is a quick update form.
I know and understand the responsibilities of myself and of Angels Service LLC
Consent to Treat: I consent to receiving services on my behalf or on the behalf of someone I have the legal right to consent to services for.
Your information is protected by HIPAA. Please email angelsservicellc@gmail.com if you would like copies of policies emailed to you.
For any special needs relates to breathing, seizures, etc. We have to complete a protcol form in order to make sure everyone has proper instructions. Some of the time this can be done in house but most of the time we will need to coordinate with your doctor for signatures on completed forms.
Do you have a physical therapist?

Seizures. Do you have seizures?*

Yes (we will be needing an action plan)No
Diabetes. Do you have diabetes or pre-diabetes?*

Yes (we will be needing an action plan)No
Respiratory . Do your have asthma, copd, or any other pulmonary needs/challenges?*

Yes (we will be needing an action plan)No
Allergies. Do you have any allergies (including to food or medicines)?*

Yes (we will be needing an action plan)No
Behaviors. Do you have any behaviors that could be dangerous to yourself or others?*

Yes (we will be needing an action plan)No
Trach. Do you have a trach?*

Yes (we will be needing an action plan)No
G/J Tube. Do you have a g/j tube?*

Yes (we will be needing an action plan)No
Diet. Do you have any special diets we will need to support during services?*

Yes (we will be needing an action plan)No
Adaptive Equipment. Do you have any adaptive equipment that will be used during services?*

Yes (we will be needing an action plan)No
Restrictions / limitations. Do you have any restrictions or limitations in relation to eating or activities?*

Yes (we will be needing an action plan)No
Heart. Do you have any heart conditions we need to know about?*

Yes (we will be needing an action plan)No
Action Plan Notes. Please provide notes regarding any 'yes' answers to the above. Please know that depending on the details we may have additional forms that need to be completed by you. If it is related to seizures or asthma that require assistance with medication please expect a form that needs to be signed by a doctor and returned.
What we will be creating with the actions plan is a 'how to' guide to respond to seizures, diet, etc. so that no matter who is helping they can read this guide and know exactly what to do when.
Click for more information regarding advance care planning for individuals and families.

Information found here:

What is advance care planning?

What is an advance directive?

Why do I need an advance directive?

What advance directive is right for me?

What should I do right now?

Tools available for indivdiuals and caregivers (also available in Spanish)
Yes I have received information regarding advanced directives
Waivers and Agreements
I have received a copy of the Agency Disclosure Form *
To safeguard your protected health information and ensure confidentiality, weencrypt external electronic communication which contains your confidentialinformation. This practice is designed to provide an extra level of securityfor your personal information, specifically, it requires ther recipient to usea password to access the message. We recognize that individuals or theirpersonal representatives may choose not to receive encrypted emails for avariety of reason. In order to opt out of this requirement, we must receivewritten notification. This release is intend to serve as that notification.*

I would like my information to be encryptedI grant my permission to send electronic communications UNENCRYPTED. This permission applies to me, my team, my providers, and anyone else who needs information on my behalf, as appropriate.
Client Details
How are things going, what are any personal updates that we need to know about? Current likes / dislikes, etc. *
Example: I am a fun hearted little girl who loves to laugh, cuddle, play puzzles, stackers, read picture books, watch movies, and ride my special three wheeled bike. I also really hate spaghetti noodles.
What would you like to get out of services / what are your current goals?
What comments you would like to share with us regarding how we can do a better job support you or the disability community as a whole?
What medicines are you taking? This is important in case something happens when we are out and a doctor needs to know or if you are receiving massage sometimes certain medicines can be contraindicated. However, if you are receiving a service where this is not relevant, such as homemaking please put NA*
Family specific house rules and religion can be a very important part of a persons life. Record any special house rules or cultural expectations that need to be taken into consideration in order for services to be provided in a considerate manner in the box.
I understand that if anything changes with the waiver funding services or any other aspect of the client profile (needs, wants, diagnoses, medications, surgeries, etc.) I must directly update AngelsServiceLLC@gmail.com in order to make sure care is provided in the best way possible.
I have received my written home care consumer rights. *
Safety Plan

In case something happens when we are at your home. :)
We are able to print you off an emergency sheet that includes information about you, your medical background, insurance, and your safety plan so that you can keep it with you, in your emergency bag, or for visitors / first responders. Would you like a copy?

Yes pleaseNo Thank you
Emergency Contacts*
Who is the legal guardian?*
Where should we shelter if we are staying in the house, such as a tornado or storm.*
Where should we meet if we need to evacuate the house but can stay in the neighborhood?*
Where should we meet if we cannot stay in the neighborhood?*
Where is your emergency supplies?-First aid kit-Extra blankets-Flashlight and batteries-At least three days of food and water
What are the escape routes from your home ?
Any information we should provider to first responders? Such as pet information or health information?*
Preferred Primary Care Doctor*
Preferred Dental Doctor*
Preferred Urgent Care Doctor*
Preferred Emergency Room Doctor*
Electronic Signature OF PERSON LEGALLY ALLOWED TO CONSENT TO SERVICES and all information received / submitted and consent to treat / participate in services. *
By typing your name you are signing this document and stating that you understand all the information and have provided truthful information. By signing you agree to all our policies and procedures. :)
Signature
Signatures for the State Mandated Forms and Intake
Annual Booklet < Clickable Link

Electronic Signature Confirmation of Receipt of Handouts*

Rows	Confirmation of Electronic Receipt of Following Documents
Home Care Agency Rights Notice
Rights
Emergency Plan
Home Care Agency Disclosure
Complaint Process
Dispute Process
Annual Disclosures Booklet

Any notes you have
Revisions:

6.28.22 Removed questions about requesting more information about advanced directivites. Add in link and headlines for CDHPE advanced directive information
Signature of receiving agency disclosure for Home Care Agency Services

First NameLast Name
Signature of receiving Home Care Agency rights notice

First NameLast Name
Should be Empty:

Updating my information!

Client Information

Waivers and Agreements

Client Details

Safety Plan

Signatures for the State Mandated Forms and Intake