Policy Manual sample

MDT Home Health Care Agency, Inc. BACK-UP SERVICE AGREEMENT Patient Name__________________________________________________________ Address_____________________________________________________________ Client’s designee for back-up services____________________________________ I, ____________________________________________, agree to the back-up service. Service provider for___________________________________________________. I agree to perform the services and have received an orientation of the services to be performed. (Attach service plan or plan of care) __________________________________________________________ Signature of back-up service provider/date I designate ___________________________________________ to be my back-up Service provider. __________________________________________________________ Patient’s Signature/date Home Health Agency. - - Personnel/Operations Policies B-91