Third-Party Plan of Care Request Form

Third-Party Plan of Care Request Form

Complete this request to obtain a copy of the patient’s proprietary Plan of Care (CMS-485) from Accucare Nursing.
Important Notice
Plan of Care is Proprietary: The Plan of Care (CMS-485) is a proprietary and custom-created document by Accucare Nursing for each individual patient. Each agency is responsible for creating its own Plan of Care. Release of this document requires both Accucare Nursing authorization and a signed consent from the patient’s parent or legal guardian.
Requesting Agency Name
Type of Organization
Contact Person Name

First NameLast Name
Contact Person Title/Role
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Agency Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Request
Acknowledgment of Requirements
Additional Comments (optional)
Note: A signed Parent/Guardian Consent for Release form must also be completed before any records are released. Accucare Nursing will review each request individually.
Should be Empty: