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25354 Evergreen Rd.
Southfield MI, 48075
Tel. 800.430.0309/Fax:248.569.2148
 
 
  Continuing Plan of Care  
Patient Name(Last, First, Middle Initial)
Address for Care  
Telephone No.
 
To Agency:

Focus Care Home Health
25354 Southfield Rd.
Southfield MI, 48075
Tel. 800-430-0309 Fax:248-569-2148

From
Patient's Address(if not same as above)
Telephone No.
Complete Date of birth
Sex Male Female
 
Referral Date
 
Reported By  
Date of First visit
 
Reported To  
Marital Status S M W D
 
Responsive Relative or Friend
Relationship
Telephone No.
Hospital Case No
Room No.
Admission Date
Discharge Date
 
Hospital for drugs & supplies
Medicare No.
Medicaid No.
PPOM No.
Name of Subscriber
Other Insurance
Policy No.
 
REPORTED BY PHYSICIAN
     
Diagnosis (List Primary First & Date of Onset)
Surgery Performed & Dates
Complications
 
Prognosis Good Fair  
  Guarded Poor  
Patient Informed of diagnosis Yes No  
Family Informed of Diagnosis Yes No  
Rehabilitation
 
  Brief Medical History
 
   
Visit to M.D. Office Clinic
   
Date of Visit
 
MEDICAL ORDERS AND PLAN OF TREATMENT
     
Diet
Activity
 
Medications Please: Check Meds. / Orders @ Home

 

Services Requested Skilled Nursing Social Worker
  Physical Therapist Speech Therapist
  Occupational Therapist HHAide
 
Durable Equipment Needed
  Lab Draws
Ordered From (Company & Tel.)
 
     
I certify that the above patient is under my care, requires that the above Home Health Services, and is confined to his/her home. These professional services are to be provided in an intermittent basis and I will review the established plan atleast every two months. These servicves are related to the diagnosis stated above and conditions for which he/ she received treatment while recently hospitalized.
Physician Name Addrerss
UPIN No. Telephone No.
License No. Date