Form DHS-5899-ENG Home Care Shared Services Agreement (Pdn or Pca) - Minnesota

Form DHS-5899-ENG is a Minnesota Department of Human Services form also known as the "Home Care Shared Services Agreement (pdn Or Pca)". The latest edition of the form was released in October 1, 2009 and is available for digital filing.

Download a PDF version of the Form DHS-5899-ENG down below or find it on Minnesota Department of Human Services Forms website.

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Clear Form Data
FILLABLE FORM
*DHS-5899-ENG*
DHS-5899-ENG
10-09
Minnesota Health Care Programs (MHCP)
Home Care Shared Services Agreement (PDN or PCA)
Complete this agreement before providing shared services for private duty nursing (PDN) or personal care assistance (PCA)
services when the recipient is approved for and has chosen to share services with other recipients. Services may be shared
between two recipients for PDN services and up to three recipients for PCA services. This agreement must be completed
annually.
Providers: Complete this form with each recipient choosing shared services. Give a copy to the recipient and keep a copy in
the recipient’s health record file.
Recipients: Read this form. If you understand and agree, sign and date this form.
RECIPIENT NAME (LAST/FIRST/MI) (please print)
RECIPIENT MHCP ID NUMBER
PROVIDER AGENCY NAME
PROVIDER AGENCY NPI/UMPI
RESPONSIBLE PARTY NAME (LAST/FIRST) (please print)
PROVIDER AGENCY REPRESENTATIVE NAME (LAST/FIRST) (please print)
By signing this agreement, I, the recipient named above, agree to:
Use shared services as directed in my care plan
Receive shared services outside my home, as shown in my care plan
Use shared services with the other recipient(s) named below
Allow the provider agency to list my name as the “Other Recipient Name” in the health service record of other recipient(s)
named below:
OTHER RECIPIENT NAME (LAST/FIRST/MI)
OTHER RECIPIENT MHCP ID NUMBER
OTHER RECIPIENT NAME (LAST/FIRST/MI)
OTHER RECIPIENT MHCP ID NUMBER
By signing this agreement, I, an authorized representative of the provider agency, agree to:
Provide shared services in and outside the recipient’s home according to the recipient’s care plan
Document on a daily basis, shared services in both the health service record and the health service records of the other
recipient(s) sharing services:
Where the shared service was provided
The start and end times of the shared service
Any notes regarding changes in condition or problems as a result of shared services
RECIPIENT SIGNATURE
DATE
RESPONSIBLE PARTY SIGNATURE
DATE
PROVIDER AGENCY REPRESENTATIVE SIGNATURE
DATE
Clear Form Data
FILLABLE FORM
*DHS-5899-ENG*
DHS-5899-ENG
10-09
Minnesota Health Care Programs (MHCP)
Home Care Shared Services Agreement (PDN or PCA)
Complete this agreement before providing shared services for private duty nursing (PDN) or personal care assistance (PCA)
services when the recipient is approved for and has chosen to share services with other recipients. Services may be shared
between two recipients for PDN services and up to three recipients for PCA services. This agreement must be completed
annually.
Providers: Complete this form with each recipient choosing shared services. Give a copy to the recipient and keep a copy in
the recipient’s health record file.
Recipients: Read this form. If you understand and agree, sign and date this form.
RECIPIENT NAME (LAST/FIRST/MI) (please print)
RECIPIENT MHCP ID NUMBER
PROVIDER AGENCY NAME
PROVIDER AGENCY NPI/UMPI
RESPONSIBLE PARTY NAME (LAST/FIRST) (please print)
PROVIDER AGENCY REPRESENTATIVE NAME (LAST/FIRST) (please print)
By signing this agreement, I, the recipient named above, agree to:
Use shared services as directed in my care plan
Receive shared services outside my home, as shown in my care plan
Use shared services with the other recipient(s) named below
Allow the provider agency to list my name as the “Other Recipient Name” in the health service record of other recipient(s)
named below:
OTHER RECIPIENT NAME (LAST/FIRST/MI)
OTHER RECIPIENT MHCP ID NUMBER
OTHER RECIPIENT NAME (LAST/FIRST/MI)
OTHER RECIPIENT MHCP ID NUMBER
By signing this agreement, I, an authorized representative of the provider agency, agree to:
Provide shared services in and outside the recipient’s home according to the recipient’s care plan
Document on a daily basis, shared services in both the health service record and the health service records of the other
recipient(s) sharing services:
Where the shared service was provided
The start and end times of the shared service
Any notes regarding changes in condition or problems as a result of shared services
RECIPIENT SIGNATURE
DATE
RESPONSIBLE PARTY SIGNATURE
DATE
PROVIDER AGENCY REPRESENTATIVE SIGNATURE
DATE

Download Form DHS-5899-ENG Home Care Shared Services Agreement (Pdn or Pca) - Minnesota

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