Design Services 5856, also known as eng form, is a document that provides specific instructions on how a design is to be produced. It covers everything from the type of paper to use, to the font size and leading. This document is used by both printers and graphic designers to ensure that all designs are created in a consistent manner. While the specifics of eng form may vary depending on your location or the printer you use, there are some general guidelines that should be followed for all designs. By understanding and following these guidelines, you can help ensure that your finished product looks professional and polished.
| Question | Answer |
|---|---|
| Form Name | Dhs 5856 Eng Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dhs 5856 eng form, dhs 5856 form, responsible party agreement sample, dhs 7576d eng |
Minnesota Health Care Programs (MHCP)
Personal Care Assistance (PCA) Program Responsible Party Agreement and Plan
Personal care assistance (PCA) agencies must have each responsible party or their delegate complete the following agreement annually to ensure they are aware of their roles and responsibilities. You must keep a copy of the completed agreement in the recipient’s file and provide a copy to the recipient and their responsible party or delegate.
Completed by Responsible Party
RESPONSIBLE PARTY NAME (Last/First/MI)
RELATIONSHIP TO RECIPIENT
RECIPIENT NAME (Last/First/MI)
RECIPIENT MHCP ID NUMBER
I agree to be the responsible party for the above named recipient for the following time period:
(MM/DD/YYYY) to |
|
(MM/DD/YYYY) and agree to (initial each): |
Attend assessments for PCA services for the recipient to help the recipient make informed choices Determine if the recipient’s health and safety are assured with the current PCA services
Help develop the PCA care plan with the qualified professional Actively participate in planning and direction of PCA services
Sign the PCA time sheets after services are provided to verify the services
Monitor the PCA weekly to ensure the care plan is followed and the care outcomes are met as described below Be accessible to the recipient and PCA when services are provided as described below
RESPONSIBLE PARTY PLAN TO MEET THE ABOVE REQUIREMENTS (Be specific - attach additional pages as needed)
Acknowledgement and Signature (check below)
l l
I am at least 18 years of age
I am not the owner or employee of the PCA provider agency
I understand that I am responsible for and have agreed to all of the duties outlined above.
Completed and Signed by Responsible Party
RESPONSIBLE PARTY SIGNATURE
DATE
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
()
The PCA agency is required to make a referral to the county common entry point for any failure to provide the support as required by the recipient.
Completed by Agency
AGENCY CONTACT NAME
TITLE
AGENCY NAME
DATE