Emergency Plan Form

* = Required Information

Patient / Client Information

Patient / Client Name *

Street Address *

City *

State *

Zip Code *

Telephone Number*

Emergency Phone Numbers

Police, Ambulance, Fire Phone Number

Primary Physician Name

Phone Number

RX Team Home Health Care, LLC 24-Hour Phone Number

Safety Liason: Administrator

Pharmacy Name

Address

Phone Number

Medical / Respiratory Equipment 24-hour Phone Number

Emergency Contact Person Name

Relationship

Phone Number

Poison Control Phone Number

Neighbor / Friend Name

Phone Number >

Disaster Priority Level

Low

Moderate

High

Reporting Abuse / Neglect

Minnesota law now requires all home health agencies to inform patients and immediate family, if appropriate, of their right to report abusive, neglectful, or exploitative practices. This abuse may be physical, mental, emotional, or financial in nature. At RX Team Home Health Care LLC our concern is the well being of our patients, as well as the community at large. To report abuse, neglect, or exploitation please call toll free 1-800-962-2873 Abuse Hotline

Medicaid Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law as it relates to Medicaid. To Report Suspected Medicaid Fraud call toll-free1-888-419-3456.