Plan of care using unlicensed proxy caregivers 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Client’s Claim Number and Start of Care Date. This information is crucial for tracking the client's care.
3. Fill in the Initial Training Date and Medical Record Number, ensuring that all dates are accurate for compliance.
4. Complete the sections regarding Frequency of Skill Recheck and Date of Annual Reevaluation. These fields help maintain oversight on caregiver performance.
5. Input the Client’s Name, Address, Telephone Number, and Date of Birth. This personal information is essential for identification and communication.
6. Document any medications, including dose, frequency, and route. Use 'N' for new or 'C' for changed medications as needed.
7. Detail any functional/physical limitations and permitted activities to guide unlicensed caregivers effectively.
8. Finally, ensure that all signatures are completed at the end of the form to validate consent and recommendations.

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