Healthcare Attendant Packet

Healthcare Attendant Packet

Patient Information

Emergency Contact

Insurance Information

Medical History

Attendant / Caregiver Information

Authorization of Services

I, the patient or authorized representative, authorize the named attendant to provide the services described below in the patient’s home or other care setting. This authorization includes access to necessary health information and performance of non-clinical and clinical tasks as expressly permitted herein. The attendant must follow the written care plan and provider orders and may not perform any procedure beyond the scope of training or licensure.

Scope of Duties (check permitted tasks)

Medication Administration

The attendant is not a licensed prescriber unless specifically credentialed. The patient authorizes only those medication-related tasks checked below. Any administration beyond the attendant’s training or licensure is prohibited.

Infection Control & Equipment

The attendant will adhere to standard precautions and infection control procedures. Personal protective equipment will be used as appropriate. The patient and/or responsible party will provide or authorize provision of required supplies unless otherwise specified below.

Privacy & HIPAA Authorization

By signing this packet the patient authorizes disclosure of protected health information to the named attendant to the extent necessary for provision of authorized services. This authorization includes medication lists, diagnoses, and care plans. The patient understands that this authorization may be revoked in writing at any time, except to the extent that actions have already been taken in reliance on it.

Liability, Indemnification & Limitations

The attendant and any employing agency shall exercise reasonable care in performing authorized duties. The attendant is not liable for adverse outcomes resulting from failure to disclose material health information by the patient or responsible party. The patient and responsible party agree to indemnify and hold harmless the attendant and agency from claims arising from acts performed within the scope of this authorization, except for willful misconduct or gross negligence.

This Packet does not replace medical advice or orders from licensed clinicians. If clinical intervention is required, the attendant will seek direction from the supervising clinician or arrange emergency services as necessary.

Termination & Amendment

This authorization may be terminated by the patient or responsible party upon written notice to the attendant or agency. The attendant or agency may also terminate services for cause or with reasonable notice. Any amendment to this Packet must be documented in writing and signed by the patient or authorized representative.

Incident Reporting & Emergencies

All incidents, injuries, or unexpected events will be documented and reported to the patient’s primary clinician and responsible party in accordance with applicable policies. In the event of an emergency the attendant will call emergency services and notify the emergency contact as soon as practicable.

Training & Competency Acknowledgment

The patient or responsible party acknowledges that authorized tasks requiring special training will be performed only by attendants who have demonstrated competency. Copies of training records and competency verification are maintained by the attendant or agency and are available upon request.

Certification and Signature

By signing below I certify that the information provided in this Healthcare Attendant Packet is true and accurate to the best of my knowledge. I have read and understand the terms, scope, limitations, and authorizations contained herein. I authorize the attendant to perform the checked services and to access necessary protected health information to carry out authorized care. I understand I may revoke this authorization in writing subject to the limitations stated above.

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