Electronic Forms

Customer Feedback Form
This is the form that should be used for reporting any customer concerns, complaints or positive feedback.

Customized Supplies Order Form

Employee Feedback Form

Employee Infection Report

Employee Occurrence Report

Employee Referral Form

Patient Transfer Report

Request for Marketing Related Events

Request For Paid Time Off (PTO)

Patient Adverse Event Report
This is the form that should be used for reporting any patient occurrence, adverse event or sentinel event.

Praise It Forward Nomination Form

Uniform Order Form

ILAH Caregiver Patient Assessment Form

Print Forms

All Companies

Care Transitions Communication Form

Environmental Safety / Infection Control Inspection Survey

New Form, Process, Policy or Procedure Cover Sheet

Orientation Time Log

Patient Adverse Event Report

Patient/Client Authorization for Release of Information

Patient PPD Report

Patient Transfer Report

Performance Evaluation Forms

Leadership Performance Evaluation Form

Team Member Performance Evaluation Form

Physician Referral Form

Physician Referral Thank You Fax Cover Sheet

Physician Signature Attestation Form

PT-INR Fax Cover Sheet

Referral Information Form

Fax Cover Sheets

Discharge Fax Cover Sheet

Physician Referral Thank You Fax Cover Sheet

Referral Fax Cover Sheet

RightHealth Clinic at the Marshes Fax Cover Sheet

PT/INR Fax Cover Sheet

THA Group Fax Cover Sheet

Transfer Fax Cover Sheet – Island Health Care

Transfer Fax Cover Sheet – Island Hospice

Employees

Direct Deposit Authorization Form

Motor Vehicle Report Consent Form

Notice Of Separation

Orientation Time Log

Technology Usage Forms

Acceptable Technology Usage Agreement

Laptop Agreement

Mobile Phone Agreement

Tablet Agreement

Bi-Weekly Time Sheet

Team Member Interview Guide A

Team Member Interview Guide B

Team Member Phone Screen

Payroll Dispute Form

Payroll Productivity Adjustment Form

Payroll Request for Educational Leave

Paid Time Off (PTO) Donation Form

Worker’s Compensation

Unplanned Absences Form

Unpaid Personal Leave of Absence Form

Finance

Allocation of Accounts Receivable Over $100

Check Request Form

Indigent/Uninsured Patient Acceptance

Indigent-Uninsured Patient Continuation of Services

Payroll Dispute Form

Payroll Productivity Adjustment Form

Payroll Request for Additional Compensation

Payroll Request for Educational Leave

Island Health Care / RightHealth

Care Transitions Communication Form

Contract for Continuation of Home Care Services

Daily Visit Log

Discharge Fax Cover Sheet

F2F Documentation Approval Form

Home Health Aide Care Plan

Home Health Aide Missed Visit

Home Health Aide Supervisory Visit

Home Health Aide Visit Note

Informed Refusal Form

Patient Adverse Event Report

Patient Transfer Report – NEW!

Physician Documentation of Face-to-Face Encounter

PT-INR Fax Cover Sheet

Risk Stratification Tool

Transfer Fax Cover Sheet_Island Health Care

Island Hospice

Bereavement Care Plan

Bereavement Contact Note

Contract for Continuation of Hospice Services

Daily Visit Log

Hospice Resident/Facility Coordination Sheet

Initial Bereavement Assessment

Medicare Hospice Benefit Revocation

NP Attestation of F2F Encounter with Beneficiary

Patient Adverse Event Report

Patient Transfer Report

Transfer Fax Cover Sheet_Island Hospice

Volunteer Health Screen Evaluation