Team Agreement Form

Birth Date Required Year must be four digits Please enter a valid date. * Invalid date

Male Female

Provider Agency or Family Member (If the Individual lives at the agency please enter the agency contact's information. If the Individual lives at home please enter the family member information.)

Contact Person for this Request (SC, Provider Agency or Family Member)

Copy Supports Coordinator Info (from above)

Copy Provider Agency/Family Info (from above)

Has Agency Nurse been notified regarding situation and PCHC involvement? Yes No

For what Health Care Issue(s) are you requesting PCHC's assistance?

All PCHC reviews are undertaken in the context of the whole person, encompassing multiple healthcare needs including: physical health, social-emotional well-being, behavioral health and environmental concerns. *

Report Recipients (Please complete information below for all persons requesting a PCHC report.)

Supports Coordinator Report Recipient:

Copy Supports Coordinator Info (from above)

Agency/Family Report Recipient (#1):

Copy Provider Agency/Family Info (from above)

Who will be responsible for dissemination of this request information?
(The completed Team Agreement Form will be emailed to the person shown below.)

Copy Supports Coordinator Info (from above)

Copy Provider Agency/Family Info (from above)

Who is the person submitting this request?

Supports Coordinator

Provider Agency/Family

Other

Agreement (Please enter the person requesting/requiring assistance, team/family members and other involved parties such as Behavior Specialist or Psychologist.)

* By submitting this request, you agree that the names entered in the Agreement Section above, provide verification that the person(s) listed is/are in agreement to receive assistance from Philadelphia Coordinated Health Care (PCHC). Please do not enter names that have not consented to PCHC assistance. You must check the Consent to Agreement check box

*** Please DO NOT hit the SUBMIT button more than once. ***

*** A CONFIRMATION PAGE will display when your submission is complete. ***

PCHC Team Agreement Form (TAF)

Individual Demographics

Supports Coordinator

Provider Agency or Family Member (If the Individual lives at the agency please enter the agency contact's information. If the Individual lives at home please enter the family member information.)

Contact Person for this Request (SC, Provider Agency or Family Member)

Provider Agency Nurse

For what Health Care Issue(s) are you requesting PCHC's assistance?

Report Recipients (Please complete information below for all persons requesting a PCHC report.)

Who will be responsible for dissemination of this request information?
(The completed Team Agreement Form will be emailed to the person shown below.)

Who is the person submitting this request?

Agreement (Please enter the person requesting/requiring assistance, team/family members and other involved parties such as Behavior Specialist or Psychologist.)

Consent to Agreement

PCHC Team Agreement Form (TAF)

Individual Demographics

Supports Coordinator

Provider Agency or Family Member (If the Individual lives at the agency please enter the agency contact's information. If the Individual lives at home please enter the family member information.)

Contact Person for this Request (SC, Provider Agency or Family Member)

Provider Agency Nurse

For what Health Care Issue(s) are you requesting PCHC's assistance?

Report Recipients (Please complete information below for all persons requesting a PCHC report.)

Who will be responsible for dissemination of this request information? (The completed Team Agreement Form will be emailed to the person shown below.)

Who is the person submitting this request?

Agreement (Please enter the person requesting/requiring assistance, team/family members and other involved parties such as Behavior Specialist or Psychologist.)

Consent to Agreement

Who will be responsible for dissemination of this request information?
(The completed Team Agreement Form will be emailed to the person shown below.)