Doea Form Hospice Adrd 001 PDF Details

In recent years, hospice care has become an increasingly popular option for those nearing the end of their lives. Hospice provides patients with comprehensive care and support in their own homes or in a dedicated hospice facility. Many people choose to enroll in hospice because they want to spend their final days surrounded by family and friends in a comfortable setting. However, before you can enroll in hospice care, your doctor must complete a hospice admittance form 001. This article will explain the contents of the hospice admittance form 001 and what it means for you and your loved ones.

QuestionAnswer
Form NameDoea Form Hospice Adrd 001
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesट्रेनिंग का फुल फॉर्म, treining ka full form, in training ful form of pt it wt, fill full form

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APPLICATION FOR

HOSPICE TRAINING PROVIDER CERTIFICATION ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING

Incorporated by reference in rule 58A-2.027 and 58A-2.028, FAC, pursuant to s. 400.6045(1) F.S.

SPECIAL INSTRUCTIONS: Please read this application carefully and fill in all of the blanks. Return the completed application along with written proof of your eligibility to:

By Regular or Express Mail:

Training Academy on Aging

School of Aging Studies University of South Florida 13301 Bruce B. Downs Blvd.

FMHI - MHC 1300

Tampa, FL 33612

FOR AGENCY USE ONLY:

ID# ____________Date

Type: ______________

Received

Acknowledged

Incomplete

Need More Information

Other ______________

Approved Comments___________________

___________________________

PART 1—APPLICANT CONTACT INFORMATION:

The information provided below is public record and reflects ownership of submitted materials.

Name: ______________________________________________________________________________________

Company Name (if applicable):____________________________________________________________

Address:____________________________________________________________________________________________________________

Apt. #

_____________________________________________________________________________________________________________________

 

City

State

Zip Code

County

Telephone: (

)___________________

Fax: (

)__________________

E-Mail:__________________________________

Part 2: Application Affidavit

I HEREBY AFFIRM THAT ALL INFORMATION INCLUDED IN THIS APPLICATION IS TRUE AND CORRECT.

Print or type name of applicant: ___________________________________________

Signature of applicant: __________________________________________________

Date: _________________

DOEA Form ADRD-002 (November 2001)

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APPLICANT CREDENTIALS

For Alzheimer’s Disease or Related Disorders Training

(Incorporated by reference in Rules 58A-2.027 and 58A-2.028, FAC, pursuant to s. 400.6045(1), F.S.)

Part 3 - Applicant Credentialing Requirements Checklist

In order to be eligible for certification, you must provide proof of one the following (see substitutions and exceptions below):

A Bachelor’s degree in a health-care, human service or gerontology related field from an accredited college or university (see substitutions below), or

Licensure as a registered nurse.

In addition to the above requirements, you must provide proof of one of the following criteria:

Possess teaching or training experience as an educator of care givers for persons with Alzheimer’s Disease or Related Disorders; or

Have one (1) year of practical experience in a program providing care to persons with Alzheimer’s Disease or Related Disorders; or

Have completed a specialized training program in Alzheimer’s Disease or Related Disorders from a university or an accredited health care or human service or gerontology continuing education provider.

Substitutions

A Master’s degree in a health-care, human service or gerontology related field from and accredited college or university may substitute for the teaching or training experience.

Teaching or training experience as an educator of caregivers for persons with Alzheimer’s Disease or Related Disorders may substitute on a year- by-year basis for the required Bachelor’s degree.

DOEA Form Hospice/ADRD-001 (September 2003)

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Part 4 – Applicant Documentation Checklist

The following documents may be used as written proof of your eligibility and must be enclosed with your application:

Copy of your final official transcripts of Baccalaureate degree in a health-care, human service or gerontology related field.

Copy of your current license as a registered nurse.

Letter from employer (on company letterhead) noting starting and ending dates of service and types of services provided to persons with Alzheimer’s Disease or Related Disorders.

Documentation of successful completion of approved university based coursework in caring for persons with Alzheimer’s Disease or Related Disorders.

Certificate/s of successful completion of specialized training program/s in caring for persons with Alzheimer’s disease or Related Disorders from a university or an accredited health care or human service or gerontology continuing education provider.

Documentation of successful completion of CEU approved presentations, workshops, or seminars in caring for persons with Alzheimer’s Disease or Related Disorders.

Copy of your final official transcripts of Master’s degree in a health related field.

Documentation of successful completion of training and continuing education consistent with the requirements of section 400.4178, or completion of training consistent with the requirements of sections 400.1755 or 400.5571, Florida Statutes.

IMPORTANT INFORMATION/INSTRUCTIONS:

Please send this application along with written proof of eligibility (see above, documentation checklist) to the address on the front of this application. No application will be accepted without written proof of eligibility.

Within thirty (30) calendar days from the date your application is received, your credentials will be reviewed and you will be sent written notification of the status of your application.

You must be an approved training provider and utilize an approved training curriculum prior to commencing training activities, pursuant to rule 58A-2.028, (1), FAC.

Please note: ANY MATERIALS SUBMITTED WITH THIS APPLICATION CANNOT BE RETURNED.

DOEA Form Hospice/ADRD-001 (September 2003)

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