HCHB-Forcura-RSL-Pointcare *

Forcura

Worker *

Referral *

Misc *

Reimbursement *

Patient *

Pointcare/RSL *

Workflow *

Scheduling *

Visit Changes *

OASIS Visit Changes *

Delete Workflow *

Reset Workflow *

Demographics Change *

Patient-Hospice *

Patient-Home Health *

SOP/SOE * Start of Period/Start Of Episode
HH: For MCR and MCR Adv payors you will use the dates for the 30 day periods not the entire cert.
mo/da/yr or mo/da/year

EOP/EOE * End of Period/End Of Episode
HH: For MCR and MCR Adv payors you will use the dates for the 30 day periods not the entire cert.
mo/da/year or mo/da/yr

Worker First & Last Name *

Medicare #/MBI *

New Payor Name * This should be the exact name listed in HCHB

New Payor Approval Coord Note * All NEW Payor and Auth Details MUST be added in Payor Approval Coord Note under the section INTERNAL PAYOR CHANGE-FOR CORPORATE USE ONLY. If this section is not filled out your ticket will be closed.

Is the New Payor a Medicare Advantage? *

New Payor Effective Date * mo/da/yr

Provider First Name *

Provider Last Name *

Specialty *

Service Code * Example: PT01

Visit Date * This date can be found in Clinical Input > Visit Notes
mo/da/yr

New Provider First & Last Name * This will be the name of the provider that should be listed on the 485/order

NPI Number *

Update Existing Or New Entry * Are you needing the contact information and address updated or a new entry added

Street Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Notify Vital Sign Alerts Via *

Notify New Order Via *

AE Home Office *

AE's First & Last Name * If credit is supposed to go to an office who is currently without an AE please enter open instead.

Prebill Auditor First & Last Name *

OASIS Type * Type of OASIS Completed

OASIS Question * Example: M0030

Is this a Job Title Change? *

Add/Remove

Branch(es)

New Visit Date * This is the date you want the visit changed to
mo/da/yr

New Worker Name * Please provide the name from Worker Console. If there are multiple employees/companies with this name please provide the Agent ID

Do orders need to be signed?

Reason For Change *

Has the order been archived in Forcura? * For 485 resets please archive the 485
For ROC resets please archive the ROC

Has the Recert been printed? *

Order Number *

Has this patient been admitted? * Payor Changes are only for patients that have been admitted. If your patient has not been admitted this would be a Referral Reset

Was this pt hospitalized? *

Date pt was admitted to hospital *

Reason For Claim Reset * A screenshot of the error is still required

Please provide the MRN this is a duplicate to *

Name Of MRS *

Which Branch(es) will they be seeing patients for? *

Visit Time Change Type *

IT Category *

Folder Access Category

Access Request Type

Display Issues

Printer Issues

Computer Issues

Phone Issues

We do not support personal devices, except adding email to a smartphone

Tablet Name *

Tablet Phone Number

Branch needing SWAT:

Person making request

Current All-In Census?

Date(s) SWAT Needed?

Current Staff, License, Status and PTO/Start dates (Mary Barry RN FT 5/3/2018- working, Geri Berry LPN FT 10/18/2019- out for two weeks etc)

Licensed Office Staff, Position, Tablet Access and any visits they are already scheduled for:

Unlicensed Office Staff and Status (Susie Jean S FT- working, Julie James, TC FT- off on PTO through 12/15)

Are all currently scheduled starts covered?

Provider SWAT available?

Regional SWAT available?

How many visits and type need to be covered over what days (10 SN, 6 OASIS between Monday and Friday)?

When and How will this crisis resolve? (new staff coming on 12/15, RN coming back from FMLA on 12/23/2020 etc)

Employee Name *

Employee Job Title *

Pay Types Choose between salary or hourly depending on pay type.

Employment Status *

Working from home? *

Exposure Location Description where the exposure occured.

Date of Onset of Symptoms: *

Date of Beginning of Covid Quarantine: * (Date of Onset of Symptoms)

Date of End of Covid Quarantine: (10 Days from Onset of Symptoms)

Does the Employee have a Positive Test? *

Date of Covid Diagnosis or Positive Test for Covid:

Have you been vaccinated? *

Have you Received any Booster Shots?

Additional Information

Survey Type *

Are all therapy companies with active contracts able to cover 100% of existing georgraphy/patients? *

Have you directly contacted your existing therapy staffing options to discuss creative ways to provide the needed coverage? *

Explain why you have not reached out to therapy staffing options *

What strategies and solutions have you been able to develop so far? *

Have you had any patients that you have had to non-admit due to lack of therapy services? *

What city/town and what services were you unable to provide? *

Are you planning to develop additional geographies in the coming months? *

Will your current therapy offerings be able to cover 100% of that area? *

Admin/Branch Manager *

Patient DOB *

Please reach out to regional.

If recertification, what is the original SOC date? *

From date: *

To date *

:

Name of Payor *

(Therapy must be donated if not FT staff.)

Who will pay for medical supplies? *

Name of Administrator *

Reason for Charity Visit (must include clinical background)

If therapy is needed, the therapist must be a full-time employee of AngMar OR documented as donated. We will not pay contract therapy. Add supporting referral documents below.

Service Line *

Medical Record Number * Please enter the MRN as it appears in Clinical Input, please do not use all zeros

Payor Source Type *

Payor Name *

Original SOC Date *

Write Off Start Date *

Write Off End Date *

Number of Periods to be Written off *

Benefit Period Date

Reason for No F2F *

Write Off Details

Has a Write Off Coord Note been entered with all details? *

Write Off Amount *

Property Management Category *

Type of Agency *

Location Checklist

Office size (sqft)

Address for Medicare approval and IT check out

Type of lease

Survey for IT cabling and service providers

Room for expansion?

Type of building

Security deposit amount

What does the space need to be move in ready ie carpet, paint, ceiling tiles etc?

Who’s responsible for the HVAC system repair / replace

What other items will the LL be responsible for?

What other items will the tenant be responsible for?

How many and how long did we get on renewal options and at what rates?

Is there an option to purchase this location later on or can we get a right of first refusal to purchase it?

Who are the Landlords contacts or representative for issues or questions?

Where does the rent check go each month and to who?

Signage Category

Signage Locations Please upload pictures of any place sign or vinyl will go.

Signage Measurement Window 1 Window 1 measurements

Signage Measurement Window 2 Window 2 measurements

Signage Measurement Window 3 Window 3 measurements

Signage Measurement Door

Signage Measurement Building

Signage Measurement Marquee

Furniture Types

Desk Type

Chair Type

Chair Count

File Cabinet Type

Conference Table Size

Type of HVAC Issue

Which department?

Type of Supplies

Type of Repair Request

Type of Pest Issue

Vendor

Training Category

Person Being Nominated

Only full-time employees are eligible to be nominated

FT or PRN

Events above and beyond expectations

Date Event or Story occurred

Story

Hospice Contract Request Form

-----------------------------------------------------------------

Submitted Date:

:

Effective Date *

Agency Legal Name:

Contractor Information

Contractor Legal Name: *

Contractor D/B/A: *

Contractor Address: *

Contractor City: *

Contractor State: *

Contractor Zip: *

Contractor County:

Contractor Contact Name: *

Contractor Phone Number: *

Contractor NPI:

Facility/Hospital

Level of Care

Facility Location of Care

Medical Director

Medical Director Type

Credentials for MD

Monthly Minimum

Hourly

Therapy

Therapy Types

ST Amount

OT Amount

PT Amount

Travel

Name of Other Hospice

Travel Start Date

Travel End Date

Visit Rate Amount (As needed)

Not Listed

Other

Hospice Start Date

Hospice End Date

Emergency Agreement

Transportation

Special Requests:

Executive Director * Please enter the name of the Executive Director responsible

Is your branch fully staffed? *

Patient Name * Please enter the first and last name as it appears in Clinical Input

Patient DOB * mo/da/yr

Requested SOC Date *

Has patient been on service before? *

Previous Dates of Service * Please list the previous dates the patient was on service

HCHB Referral Completed * All referrals must be entered into HCHB

Insurance Benefits Verified * Have the insurance benefits been verified by the Insurance Verifications team at Corporate?

Does the patient have a payor? *

Payor Name(s) * Please list all insurance the patient has

Is the patient pending Medicaid? *

Service Location * ALF, Home, SNF, etc

Referring Physician *

New Referral Source *

Reason for Charity Visit-must include clinical background * If therapy is needed, the therapist must be a full-time employee of AngMar OR documented as donated. We will not pay contract therapy. Attach supporting referral documents below.

Number of Aide Visits *

Number of Occupational Therapy Visits *

Number Of Physical Therapy Visits *

Number of Skilled Nurse Visits *

Number of Speech Therapy Visits *

Number of Chaplain Visits *

Number of Social Worker Visits *

Room & Board Coverage *

Medical Supplies

Medications

DME

Number of Current Charity Patients *

Current Census *

Heat Map Type * Counties: Please be sure to list only counties assigned to your branch
City: Please submit a ticket for each requested city.

Counties Requested * Please be sure to list only counties assigned to your branch

City Requested * Please enter the city you are requesting a heat map for. Please remember each city requires an individual ticket.

Name *

Email *

Department *

Location *

Subject *

Supply Order Type *

Please read the Business Development and Clinical Marketing Supply Order guidelines below:

• All Marketing Supply Order forms must be approved by your Branch Manager (if applicable), Administrator and Regional Director prior to submission to Corporate for approval and production. All completed MSOs are to be submitted by the Regional Director of Business Operations only via the marketingsupplyorders@angmarcompanies.com email.

• Marketing Supply Orders submitted on outdated forms will NOT be accepted. Offices should download the current MSO form from the shared drive prior to submission (form is dated).

• Any questions regarding outstanding Business Development or Clinical orders should be directed to Mallory Peek at mallory.peek@angmarcompanies or 817-539-2420.

• Orders that are faxed to Corporate without all signatures included on the signature lines noted will not be accepted. No verbal or email approvals will be accepted.

• Please send all questions about staff name/photo badges to Brooke Vangulder at brook.vanguilder@angmarcompanies.com.
- Branch, Employee Name, Credentials (if applicable) and Job Title should be included in the email.

• A proof of Business Cards, if applicable, will be sent for approval prior to ordering. Note that business cards are provided for Administrators, Branch Managers, DONs and Account Executives. Business cards for RNs, BHRNs, LPN/LVNs, and other office staff are available by request only and timely response to these emails will ensure a faster turnaround. Information needed for business cards include:
- Employee Name, Credentials, Job Title
- Write in the cell phone number if Employee chooses to include it on the card (optional for inclusion)

• MSO items are processed using multiple vendors, therefore you may receive multiple boxes and should allow 2-4 weeks for your items to arrive. All items are shipped “ground.”

• If you are ordering items for an event(s), please provide the date of the event(s) on the signature page of the MSO, where noted, so we can work with our vendors to ensure your items arrive in time and avoid additional fees for “Rush Shipping.” See previous bullet regarding shipping timeframes and plan accordingly.

• Brochures and other novelty items should be ordered in quantities specified.

• New hire business cards (if applicable), standard name badges and photo badges should not be submitted via MSO as these are standard items that will be processed when new hire paperwork is complete at Corporate. MSO is to be used for REORDER of these items only

Division Vice Presidents: Central Division:

Alicia Hendrix (Regions 2 & 3)
North Division: Lisa Everage (Regions 1, 6, & 7)
Western Division: Beth Blackburn (Regions 4 & 5)

Region	Regional Director	E-Fax Number
(1) Florida	Amanda Uhl	817-549-6548
(2) South Texas	Kerry Layfield	817-549-7990
(3) Oklahoma	Kristin King	817-549-6714
(4) Central Texas	Shannon Gebauer	888-587-9343
(5) Arizona	Amanda Uhl	817-549-6548
(6) Nebraska/Iowa/Indiana	Sue Anne Watts	817-549-7046
(7) Kansas/Ohio	Amy DeWitt	817-549-6746

Specialty Program Custom Packets *

Disease Management Program

Includes Diabetes DMP booklet, Diabetes DMP zone card, and Diabetes DMP folder.

Quantity Needed Diabetes Packet

Current Inventory for Diabetes Packet *

Skin and Wound Care: Living Well with an Ostomy

Message *

Payor Change Type * From SOC: Patients where the payor has been incorrect since SOC. These are only to be submitted by Reimbursement

Mid Admission: The patient's payor changed AFTER we admitted them. These are to be submitted by the branch

z- do not use HCHB/Pointcare/RSL/Forcura Category Please select a subcategory for HCHB.

Contact Us

We do not support personal devices, except adding email to a smartphone

Branch needing SWAT:

Reason for Charity Visit (must include clinical background)

Skin and Wound Care: Living Well with an Ostomy

Skin and Wound Care: Living Well with an Ostomy

Skin and Wound Care: Living Well with an Ostomy