Referral Form Name: Branch #: Date: Phone Fax: Manager Email: Call Case Manager before contacting Case Voucher Warning 1 2 Task List attached Two Weeks total hours Name: Address: Primary Language: Consumer Primary Contact: Representative: Phone/email: Consumer-Employed Provider OPI ICP Consumer-Employer Prime Number: State Plan Personal Care Spousal Pay Contact Case Manager for Details, send Employer Responsibilities Review form 0737, etc. Other/details: Overview/Review New to in-home services New Representative Hiring Terminating Needs list of HCWs from Registry Topics apply) Communicating needs and expectations that Boundaries all Back-Up planning Emergency planning and safety Recommended (check Transitioning from NF/AFH/other: Scheduling multiple HCWs Voucher > 10% of authorized hours. Training Consultant: to: with List Email: Send Task Oregon Home Care Commission Employer Resource Connection is a program of the For more information, call 877.867.0077; and listen for the option or email
Referral Form Case Manager Name: Branch #: Date: Fax: Email: Call Case Manager before contacting Task List attached Two Weeks total hours Voucher Warning 1 2 Consumer-Employer Name: Address: Primary Language: Primary Contact: Consumer Representative: Phone/email: Prime Number: Consumer-Employed Provider OPI ICP State Plan Personal Care Spousal Pay Employer Responsibilities Review Contact Case Manager for Details, send form 0737, etc. Recommended Topics (check all that apply) Overview/Review Other/details: New to in-home services New Representative Hiring Terminating Needs list of HCWs from Registry Communicating needs and expectations Boundaries Back-Up planning Emergency planning and safety Transitioning from NF/AFH/other: Scheduling multiple HCWs Voucher > 10% of authorized hours. Send with Task List to: Training Consultant: Phone Email: Employer Resource Connection is a program of the Oregon Home Care Commission For more information, call 877.867.0077; and listen for the option or email
ERC%20APD%20Referral%20Form%205-2018.docx