Forms and Documents

Forms for Prospective and Existing Clients

• Documentation of Face to Face Encounter for MEDICAID Patients - The purpose of this form is to comply with Home Health Services: Section 6407(b) of the Affordable Care Act (ACA) and implementing federal regulations require that no payment may be made by a state Medicaid Program for home health services, unless the prescribing physician documents that the physician or NPP had a face-to-face encounter with the MA beneficiary. The face-to-face encounter must be related to the primary reason the MA beneficiary requires home health services. The face-to-face encounter must occur within 90 days prior to or 30 days after the initiation of home health services, although it is expected that ordinarily the face-to-face encounter will occur prior to the start of services. The federally authorized NPPs able to perform face-to-face encounters for nursing, home health aide, physical therapy, occupational therapy, speech pathology and audiology services are: PAs, CRNPs, CNMs and CNSs. 

• Minnesota Living Will Brochure

• Intake Request Form - Please Note: An intake request that is filled out and faxed to us is not an acknowledgement of any acceptance of services until approved by Director of Nursing.
  
  
• Home Care Bill of Rights

Forms For Prospective Employee's

• Nurse Employment Application
• Paraprofessional Employment Application
• MN CBC Privacy Notice MDH

Nondiscrimination statement :

• Nondiscrimination Notice

Equity Services is an Equal Opportunity Employer. Equity Services of St Paul Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.