SHHS Kansas City Monthly Monitoring

Superior Home Health Services Kansas City

Monthly Monitoring Form
4380 N Oak Trafficway Suite 204

Kansas City, Mo 64116

Phone # 816-382-3405 Fax is 816-382-3405
Consumer Name:
DCN:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Note:
Phone Number:

Area CodePhone Number
Date and Time:
1. Are you satisfied with the CDS service provided through Superior Home Health Services?
2. Are SHHS staff helpful with directing your services?
3. Is there anything we can doto assist you with independent living?
4. Are you satisfied with your attendant?
5. Please name any personal goals you have:
A. ExcellentB. GoodC. FairD. Could be betterF. Poor
7. Are you aware of any fraudulent activity pertaining to your care or anyone else’s care?
8. Have you been hospitalized this month? If so what dates?
Before signing this document, verify that the content you are signing is correct.
Case Manager:
Date:

MonthDayYear
Date
Signature
Attendant:
Date:

MonthDayYear
Date
Signature
Consumer:
Date:

MonthDayYear
Date
Signature
Home VisitPhone Call
Should be Empty:

Superior Home Health Services Kansas City