Host Home Provider Documents and Forms

Please find medication and doctor’s visits forms below. Remember to fax/email/SCOMM all pages to your PPCH Nurse within 24 hours of client’s appointment.

Annual Physical Form

Psych Diagnosis Form

Once yearly, bring Annual Physical Form to PCP and Psych Diagnosis Form to Psychiatry appointments for physician to fill out and sign.

PRN List 2021

Please ensure the PRN list is signed yearly, if applicable, by the PCP. 

Controlled Drug Count

Fill out this form whenever you administer controlled drugs to a client. This is required for all QMAPS. Once the count is down to zero, fax/email/SCOMM the completed form to your PPCH nurse. If the controlled drug is “as needed” and there are remaining pills not taken by the client, turn in remaining pills in original bottle with count sheet to your PPCH nurse or PD. Remember to fill out the entire form, including the date/ year, drug name, dosage, frequency, and RX number.