Emergency Plan Manual

AHCA Form 3110-1022, Rev March 2013 Rule 59A-8.027, Florida Administrative Code http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Home_Care/HHA/index.shtml#other . Page 17 of 54 APPENDIX A: AGREEMENTS AND UNDERSTANDINGS MUTUAL AID AGREEMENT OR STATEMENT OF UNDERSTANDING Under Emergency Situations This agreement is made in good faith between _______________________________________ and _______________________________ (name of agency) Mutually agree as follows: x That_________________________ health facility will act in cooperation with our agency, in relation to patient services under Emergency Situations (such as Hurricanes, Tornados, Floods, etc.) x The health facility shall serve our patients needs if our employees are unable to do so due to closure of our office for Emergency Situations or inability to reach the patients because of said incident. x The _____________________________ (name of agency) shall return to our agency the clients/patients transferred to them under Emergency Situations, when our facility is fully operational, after normal hors are re-established, and our employees are able to provide the care of our patients ordered by the physicians. x The Patient’s information will be used only for the purposes for which it was engaged by the service provided, will safeguard the information for misuse, and will help the agency comply with some of the Agency’s duties under the HIPPA Privacy Rule. All records information will be maintained as “Confidential” Signed by: ________________________ Signed by: _________________________ Administrator Administrator Print Name: _______________________________ Name of Agency: _______________________________ Contact Number: _______________________________ Date: ________________________ Print Name: ________________________________ Name of Agency: ________________________________ Contact Number: _________________________________ Date: _________________________ Angel Home Care Services, Inc. NILA A. ALEGRE nalegre@angelhcs.com Angel Home Care Services, Inc. (305) 220-4544 Angel Home Care Services, Inc.