FAX to-905-771-2764 Shared Care--Long Term Care--Group Home Faxes ONLY
STAFF SIGN-IN/OUT & CLIENT SIGNATURE
Name of Home: (please use 1 fax sheet per Home)
Address of Home: Staff Name + Emp. # Please Print
Date
Client Name
please print
Time In
Time Out
Client’s Signature
Client Goldcare #
Please Only Fax to: 905-771-2764 Non-use of Telephony Home Visit Confirmation Please have your client or Substitute Decision Maker sign verifying your visit start and end time.
A separate sheet MUST be used for each client, and faxed in the day of the visit. Please print clearly, all lines must be filled out.
DATE:_____________________________________________
Employee Name:__________________________________________ Employee Number:_________________________________________
CLIENT NAME:_______________________________________________________________________
GOLDCARE # (if known)________________________________
CLIENT ADDRESS:___________________________________________________________________________________________________________________________
Visit Start Time:_____________________________________ Visit End Time: ——————————————————————
Client or SDM Signature:__________________________________________________________________________________________________________________________
Visit Start Time:_____________________________________ Visit End Time: ——————————————————————
Client or SDM Signature:__________________________________________________________________________________________________________________________
Visit Start Time:_____________________________________ Visit End Time: ——————————————————————
Client or SDM Signature:__________________________________________________________________________________________________________________________
REASON FOR NON-USE OF TELEPHONY VISIT
This fax form is only to be used and faxed in when any of these conditions apply: CONFIRMATION:__________________________________________________________________________________________ If you have any concerns please contact your Client has not authorized telephone use. (this information is on file at PHCS)
Nurse Manager or Client Care Specialist.
Client has a rotary phone.
1-877-924-8800
Client resides in a Shared-Care, Long Term Care Home, or Group Home.
905-771-2766
You have forgotten to sign in and out. Any circumstance that has interfered with you using telephony.