Ohio Form Jfs 02390 – Fill Out and Use This PDF

Print the Individual Name (Please print), then fill in the Medicaid Billing # and the Individual Street Address, City, State and Zip Code.

Trainer: enter the medically necessary skilled task(s) the Home Care Attendant has successfully completed training to perform, and draw a single line through any unused boxes.

Authorizing health care professional (AHP): place initials in the box for each approved task(s).

The individual/authorized representative has received the necessary training and is electing to select, instruct and direct the Home Care Attendant (HCA) to perform the task(s) set forth on this form, and will ensure that the HCA performs the task(s) consistent with her/his training and in accordance with OAC Rule 5160-46-04.1, as appropriate.

This authorization may be revoked at any time by the authorizing health care professional, and the individual is responsible for reporting any changes in health or circumstances to the Case Management Agency (CMA) Case Manager, Trainer, HCA, and Authorizing Health Care Professional.

Individual/Authorized Representative: print Name (Please print), then Signature, Initials and Date Signed.

Under Home Care Attendant, the undersigned has received training in the task(s) set forth on this form and will perform the task(s) in accordance with OAC Rule 5160-46-04.1, as appropriate, and as trained by the individual, authorized representative and/or trainer. The undersigned is approved to perform the listed task(s) for this individual, and understands that ODM may revoke that approval at any time if deemed necessary.

Under Home Care Attendant, the undersigned is responsible for reporting any changes in her/his ability to perform the task(s) to the Individual, CMA Case Manager, Trainer, and Authorizing Health Care Professional.

Home Care Attendant: Name (Please print), Signature, Initials and Date Signed.

Under Trainer (Please read before signing and dating), the undersigned verify that the Home Care Attendant has successfully been trained to perform the task(s) set forth on this form.

Trainer Name (Please print), Signature, Initials and Date Signed.

Under Authorizing Health Care Professional and Trainer, the undersigned approves the individual's decision to select, instruct and direct the Home Care Attendant in the performance of the task(s) set forth on this form, and may revoke approval at any time, if deemed necessary, by notifying the Individual/Authorized Representative, CMA Case Manager, and Trainer.

Name (Please print), Signature, Initials, Date Signed, Emergency Phone Number (Including Area Code) and Fax Number (Including Area Code).

In the event that no physician is aware of or supports the individual's decision to use the Home Care Attendant option, the Registered Nurse who is serving as the Authorizing Health Care Professional must be made aware of the physician's exclusion or non-support.

Add the Customer/Authorized Representative (Initials) and the Authorizing Health Care Professional (Initials) on the lines.

Fill in the Individual Name (Please print), the Trainer Name (Please print) and the Effective Period (not to exceed 12 months) with a Start Date and an End Date.

Trainer: enter the name of the medically necessary skilled task required by the individual under Name of Task.

Enter the date the Home Care Attendant (HCA) completed training to successfully perform the skilled task, and write a detailed description of how HCA will perform the task, including times or intervals.

If the individual/authorized representative is the trainer, the individual/authorized representative will complete this section.

Check here if CONTINUED on next page.

The HCA is not approved to perform the listed task(s) until though AHP has initialed the Training Detail page.

Authorizing Health Care Professional: My initials indicate approval of this task to be performed by the Home Care Attendant and that the Home Care Attendant has demonstrated the ability to perform the task. Initial here.