Disclaimer: Information and education provided by PCHC is
intended as general information only and is not all inclusive or
intended to replace physical, dental or behavioral health advice.
If you believe that you, or someone you support, have physical,
dental or behavioral health issues, please seek professional advice.
All PCHC forms are in PDF format and open in a new browser window. If you do not have
Adobe Reader to view PDF files, please
click here to download a free copy.
PCHC Forms
Click on a specific link to open the form in Adobe PDF format.
- Behavorial Health Team
Review Form
(PDF File)
The Behavioral Health Team Review form (TRF) is a 3-page form that is
used to review psychotropic medications. Use of this form can enhance
communication between residential staff, behavior specialists, psychiatrists
and all team members. It can improve quality of care for the person being
supported through proper documentation of target symptoms, diagnosis,
and treatment.
- Health Information Recording System (HIRS) Appendix Forms
There are 13 HIRS forms found in the appendix section of the
Health Information Recording
System (HIRS) publication. To download a HIRS Appendix form, click on the
form name in the drop down menu below.
- Special Services Fund
Application
(PDF File)
The Special Services Fund form is used only for Philadelphia Pennhurst
class members and Dual class members (Pennhurst and Embreeville).
If an individual needs health care services or products
(e.g., hearing aides, orthopedic shoes) that are not covered or are denied
by Medical Assistance, Medicare or private insurance, this form can be
submitted to PCHC for funding consideration. All requests should be
submitted with the proper documentation and/or denial letters. Cost for
services and/or products must be reasonable.
- Team Agreement Form
(PDF File)
Updated!
The Team Agreement Form is used to facilitate interdisciplinary communication,
when requesting training, clinical reviews, team meetings, and community health
reviews. It is to be submitted to PCHC when requesting clinical supports.
- Training Request Form
(PDF File)
The Training Request Form is used to request training presentations from PCHC
staff. The form is to be submitted to the Educational department.