Enrollment Form for Premier Nurse Delegation

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Adult family home information

Tell us about your home. Fields marked * are required.

AFH name *

Street address *

City *

Zip code *

Primary AFH provider

AFH provider full name *

Cell phone *

AFH phone

Fax number

Email address *

2nd contact person (optional)

Full name

Phone number

Title / role

How did you hear about us?

Client information

Only list clients who need nurse delegation. You can add up to 6 clients.

Yes — I have clients ready to enroll

No — setting up my home, will add clients later

Client 1

Client full name (last, first) *

Date of birth *

Client type *

Where is this client currently residing? *

Facility name and phone number

If transferring from another facility, please provide name and phone number.

State / Medicaid — case manager info

Case manager name

Case manager phone

Case manager email

Medication list

Upload MAR or current medication list

Upload medication list or MAR

PDF, JPG, PNG accepted. Max 10MB.

Private pay — additional required

Upload current client assessment *

Required for all private-pay clients. Resident and POA must be aware of nurse delegation services and fees.

Caregivers to be delegated

Add each caregiver who will be performing delegated nursing tasks. Upload documents will change based on credential type.

Caregiver 1

Full name *

Credential type *

CNA

HCA-C

NAR

CNA Required documents

CNA certificate / credential copy *

Upload document

9-hour nurse delegation certificate *

Upload document

3-hour diabetes certificate *

Upload document

HCA-C Required documents

HCA-C certificate / credential copy *

Upload document

9-hour nurse delegation certificate *

Upload document

3-hour diabetes certificate *

Upload document

NAR Required documents

NAR certificate / credential copy *

Upload document

9-hour nurse delegation certificate *

Upload document

Core Basic / 75-hour DSHS training certificate *

Upload document

3-hour diabetes certificate *

Upload document

Private pay acknowledgments

Please type your initials in each box to confirm you have read and understood each statement.

"Resident and POA are aware of nurse delegation services and the associated service fees for Premier Nurse Delegation."

Your initials *

"I understand the billing method: Premier Nurse Delegation will bill the AFH Provider on the day of the visit. The AFH will pay for the visit, then seek reimbursement from the Resident or POA. An invoice will be provided for each delegated resident at each visit."

Your initials *

"I understand that Premier Nurse Delegation may rescind or end nurse delegation services if payment is delinquent for over 90 days."

Your initials *

"I understand that private-pay client placement and yearly assessments are referred to a separate nurse assessor. Premier Nurse Delegation's primary focus is nurse delegation services."

Your initials *