ATTENTIVE HOME CARE

AUTHORIZATION FOR EMERGENCY PROCEDURE PLAN

Agency 24-Hour Number: 612-447-5958

In the event of a medical or situational emergency, activate my emergency plan as stated below. I authorize you to use your judgment in this matter and arrange for needed transportation and/or services.

CLIENT'S NAME

Name:

DOB:

Address:

City:

State:

Phone#:

PHYSICIAN INFORMATION

Name:

Address:

City:

State:

Phone#:

Allergies:

Oxygen/Ventilator Provider:

Electric Company:

Gas Company:

Water Provider:

Equipment Provider:_

Pharmacy:

EMERGENCY PHONE 911

HOSPITAL:

City

Phone#:

ADVANCE DIRECTIVE:

If Yes, Type:

CaseManager:

Phone#:

CLASSIFICATION: (circle one) Client is LEVEL

LEVEL 1: No caregiver in home or readily available; dependent on others to meet physical or safety needs – you
are a HIGH PRIORITY for staffing
LEVEL 2: Use assistive devices – could manage alone for time period of 24-48 hours; able to take medications
or get food if available at home. RN will contact to coordinate needs and services. You will be
contacted by the agency by phone.
LEVEL 3: Able to manage alone for more than 72 hours or has available caregivers or other support systems in
place. Manages own medications and diet. You will be contacted by the agency before your
next scheduled visit or shift.

Client Signature

Witness

Date

Date

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