PCHC Forms

You can download all PCHC forms from this web page. If you have questions about the use of our forms, take a look at our PCHC Forms Training. This training can be used to:

iStock 000015553546 Large
  • Identify forms that may aid you in supporting individuals with ID
  • Explain the purpose of each form
  • Describe the benefits of using each form as well as the nuances
  • Clarify the process for submitting a form and requesting services from PCHC (including contact persons)

 

  • American Cancer Society Form

    DOWNLOAD:  American Cancer Society Service Referral Form

    By completing this form, representatives from the American Cancer Society will contact people with information about what services and supports are available. Use this form along with the PCHC Cancer Support Notification Form.

  • Annual Physical Examination Form

    DOWNLOAD:  Annual Physical Exam Form and Annual Physical Exam Form Letter

    This form and the accompanying document, Intermediate Care Facility/Intellectual Disability [ICF/ID] Level of Care Certification, meet waiver certification and recertification requirements and has been endorsed by the counties in the Southeast Region of Pennsylvania. The use of this form will foster consistency in collecting comprehensive health information while providing community health care practitioners with an instrument that is familiar among their patients with Intellectual/Developmental Disabilities .

  • Behavorial Health Team Review Form of Psychotropic Medications

    DOWNLOAD:  Behavioral Health Team Review Form of Psychotropic Medications

    This form is used to review psychotropic medications. A description and instructions on how to use the form can be accessed here

    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 Tool (DST)

    DOWNLOAD:  

     

    ADDITIONAL TOOLS FOR DOWNLOAD:  

     

    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 ID.

    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.

    These forms were developed through PCHC's Alzheimer/Dementia Initiative.

  • Dental Levels of Care Form

    This form was created as a direct result of a dental grant awarded through the Pennsylvania Developmental Disability Council. PCHC partnered with Achieva to help create this form to:

    - to help individuals with disabilities, families, Special Needs Units at MCOs and dental offices identify the dentist best able to provide treatment

    - to provide necessary information for the dentist to best support each individual

    - to help provide Special Needs Units at MCOs with more information when making referrals for members and dentists

    - to encourage more community dentists to treat individuals with disabilities 

    Please view this webinar for more instructions on the use of this form:
    https://www.achieva.info/levels-care-what-kind-dentist-do-i-need-0

     

  • Documentation Requirements for Integrated Health Clinical Reviews

    DOWNLOAD:  Documentation Requirements for Integrated Health Clinical Reviews

    The form is designed as a checklist and outlines all documentation that PCHC requires in order to complete an adequate Clinical Review. This form should be submitted to PCHC with copies of the accompanying documentation before a Clinical Review will be scheduled. 

  • Dysphagia: Considerations for Risk Management Form

    DOWNLOAD:   Dysphagia:  Considerations for Risk Management Form 

    This tool was created to assist risk managers when reviewing incidents regarding choking.  Other questions and suggestions may be necessary depending on the circumstances of an incident.

  • Eating, Drinking and Swallowing Checklist

    DOWNLOAD:   Eating, Drinking and Swallowing Checklist(in English) and in bilingual Spanish

    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.

    This checklist 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.

    You may also find related resources within the Dysphagia Resource Directory.


    PCHC “Lista de Verificación de Comer, Beber y Tragar” es un instrumento creado para ayudar a los cuidadores de familiares con impedimentos a identificar potenciales signos y/o síntomas de Disfagia. El principal aporte de la “Lista de Verificación de Comer, Beber y Tragar” es ayudar a identificar indicativos de Disfagia. PCHC ayudo en la elaboración y publicación de esta lista de comprobación para el uso de cualquier persona que apoya a las personas con discapacidad intelectual (I.D.). Este formato deberá ser completado anualmente como requisito de las personas y deberá ser revisado por el doctor familiar. El Directorio de Recursos de Disfagia está disponible en Ingles y ofrece información, instrucciones, recursos, ejemplos y materiales de capacitación para apoyar a las personas que viven con Disfagia.

  • Falls: Consideration for Risk Management Form

    DOWNLOAD:   Falls: Considerations for Risk Management Form 

    The Falls: Considerations for Risk Management document was created to assist risk managers when reviewing incidents regarding falls. This list is not all inclusive but was created to stimulate further discussion.

  • Family Health History Form

    DOWNLOAD:  Family Health History Form

    This form is required to be completed prior to scheduling a PCHC Clinical Review. This form is designed as a checklist outlining both physical and mental health concerns within the family system. The purpose of this form is designed to aid in uncovering possible physical and/or psychiatric problems.

  • Family Health Information Recording System (HIRS)

    DOWNLOAD:  Family HIRS and bilingual (Spanish) Family HIRS

    These forms were developed for use by families providing services for their family member at home. The more complex the medical needs of someone living at home, the greater the need to organize the person's health information.

    The Family HIRS utilizes many of the same forms used in the HIRS (see below), but has additional forms and information to meet the specific needs of families.

  • Health Information Recording System (HIRS)

  • Nursing Home Review Panel - Hospital Admission Follow Up Form

    DOWNLOAD:  Hospital Admission Follow Up Form

    This form needs to be submitted to the Nursing Home Review Panel whenever a Pennhurst or Embreeville class member, registered in Philadelphia, is admitted to a hospital. The Hospital Admission Follow Up Form needs to be resubmitted anytime there is a change in the placement of the class member who has been hospitalized. The Hospital Admission Follow Up Form is submitted by the Supports Coordinator assigned to the class member.

    Please refer to the brochure for more information Nursing Home Panel Review Brochure

         Fax:  Jack Toomey, RN at 215-790-4976
    E-mail:  This email address is being protected from spambots. You need JavaScript enabled to view it. as an attachment
        Mail:  PCHC at 123 S. Broad Street, 22nd Floor, Philadelphia, PA 19109

  • PCHC Cancer Support Notification Form

    DOWNLOAD:  PCHC Cancer Support Notification Form

    The 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

    DOWNLOAD:  Special Services Fund Application

    This 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. The cost for health care services and/or products must be reasonable.  

  • Team Agreement Form

    DOWNLOAD:  Team Agreement Form

    The Team Agreement Form is submitted to PCHC when requesting clinical supports. It is used to facilitate interdisciplinary communication when requesting a clinical review, team meeting, and/or community health review. 

  • Training Request Form

    DOWNLOAD:  Training Request Form

    This form can be used to request training presentations from our staff. Please fax your completed form to our Training Fax #: 215.599.5180. You may also complete and submit our online Training Request Form

  • 1