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Professional Emergency Contacts Sheet template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Immediate family, durable power of attorney, and healthcare decision-maker contacts.
Emergency transport consent, hospital choice, and advance directive reference.
Cardiologist, neurologist, DSHS case manager, and ombudsman contact numbers.
Laminated wall-mount format for quick caregiver access during night shifts.
Or get this form included in the Operations & Records Bundle ($69)