Disclaimer: Information and education provided by PCHC is
intended as general information only and is not all inclusive or
intended to replace physical, dental or behavioral health advice.
If you believe that you, or someone you support, have physical,
dental or behavioral health issues, please seek professional advice.
PCHC Forms
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- Automatic Patient Referral
Form
By completing this form, representatives from the American Cancer
Society will contact people with information about what services
and supports are available.
- Behavorial Health Team
Review Form
The Behavioral Health Team Review form (TRF) is a 3-page form that is
used to review psychotropic medications. Use of this form can enhance
communication between residential staff, behavior specialists, psychiatrists
and all team members. It can improve quality of care for the person being
supported through proper documentation of target symptoms, diagnosis,
and treatment.
- Dementia Screening Tools
These tools can be used to help identify changes in a person's functioning
level that may attribute to early signs of a medical/behavioral health
condition including dementia for people with I/DD. Completion of the
form must be done through direct observation. The criteria for
completing this form is listed on the top of the front page.
There are sections for both physician, residential and
day services. A cover sheet is included which lists further testing
that may be ordered by the physician. The information collected should
be shared with the person's primary care physician for further
follow-up and treatment.
- Health Information Recording System (HIRS) Appendix Forms
There are 13 HIRS forms found in the appendix section of the
Health Information Recording
System (HIRS) publication. To download a HIRS Appendix form, click on the
form name in the drop down menu below.
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- PCHC Cancer Support
Notification Form
The PCHC Cancer Support Notification Form allows PCHC to follow-up on
the ACS Service Referral Form requests as well as offer supports through
PCHC such as information and training.
- Special Services Fund
Application
The Special Services Fund form is used only for Philadelphia Pennhurst
class members and Dual class members (Pennhurst and Embreeville).
If an individual needs health care services or products
(e.g., hearing aides, orthopedic shoes) that are not covered or are denied
by Medical Assistance, Medicare or private insurance, this form can be
submitted to PCHC for funding consideration. All requests should be
submitted with the proper documentation and/or denial letters. Cost for
services and/or products must be reasonable.
- Swallowing Checklist
This checklist can be used to help identify whether or not someone is at
risk for Dysphagia or other related choking issues by identifying signs
and symptoms. It is not a diagnostic tool! It should be completed by
support staff or caretakers while observing an individual eating. It is
a way to alert the person's primary care physician (PCP) about any visible
signs or problems with eating, drinking or swallowing. It should be completed
on an annual basis or if someone shows signs of problems when eating
(e.g., coughing, losing food from their mouth, gurgly voice, etc.).
The information collected should be shared with the person's PCP.
- Team Agreement Form
The Team Agreement Form is used to facilitate interdisciplinary communication,
when requesting training, clinical reviews, team meetings, and community health
reviews. It is to be submitted to PCHC when requesting clinical supports.
- Training Request Form
The Training Request Form is used to request training presentations from PCHC
staff. The form is to be submitted to the Educational department.