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Click ‘Get Form’ to open it in the editor.
Begin by entering the CLIENT NAME in the designated field at the top of the form. Ensure you include the first name, middle initial, and last name for accurate identification.
Fill in your HOME HEALTH AIDE NAME similarly, providing your first name, middle initial, and last name.
Indicate the week of service by filling in the dates for Sunday through Saturday. Use the MM/DD format for clarity.
For each day of service, record TIME IN and TIME OUT. Be sure to circle AM or PM as appropriate.
Document daily total hours worked and calculate TOTAL HOURS FOR WEEK at the end of this section.
In the CARES PERFORMED section, ensure staff initials are documented next to each service provided. Note any refusals as required.
Complete CLIENT SIGNATURE and HOME HEALTH AIDE SIGNATURE sections with dates before submission.

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