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 20 of 54 APPENDIX C: SUPPORT MATERIAL PATIENTS WHO NEED CONTINUED SERVICES DURING AN EMERGENCY (Prioritized List) Med. Rec. Patient’s Name and Address Phone Actual Main Services How services will continue Special needs shelter (Y/N) Name/ Address / Phone Medication Equipment list updated (Y/N) Pt needs to be transferred (Y/N) Receive Skilled Care (Y/N) Category: _________ Observation:_________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Angel Home Care Services, Inc.