Form Hcs 001 - Home Care Organization Suboffice Request Page 2
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2HOME CARE ORGANIZATION SUBOFFICE REQUEST INSTRUCTIONS:
Please type or print clearly and ensure that the form is filled out completely.
• Request Type: Check appropriate box.
• Section A: Home Care Organization Information
o Home Care Organization Name: Enter the name used to designate the primary Home Care Organization.
o Home Care Organization Number: Enter the Home Care Organization Number for the primary Home Care
Organization.
o Home Care Organization Address: Enter the physical location address of the Home Care Organization.
o Licensee(s): Enter the name(s) of the person(s) or organization legally responsible for the primary
Home Care Organization. Enter full names (Individuals enter first, middle name, and last name). Please enter
the area code with telephone number of the Home Care Organization.
• Section B: Suboffice Information
o Suboffice Address: Enter the physical location address of the suboffice.
o Operating Days and Operating Hours: Enter the day and hours that the suboffice will be utilized. The
suboffice cannot be used more than 24 hours within a seven calendar day time period.
• Section C: Suboffice Designee
o Designee Name and Title: Please enter the name and title of person who will represent the suboffice.
• Section D: Questions
1. Please explain the primary purpose of the suboffice including how the Home Care Organization will utilize the
suboffice.
2a. Please describe how the Home Care Organization will ensure that staff is not present at the suboffice full-time
(no more than 24 hours within a seven calendar day time period).
2b. Please describe how the Home Care Organization will ensure that confidential records containing client, staff,
volunteer, or Home Care Aide personal identifying information will not be permanently stored at the suboffice.
HCS 001 (12/15)
PAGE 2 OF 2
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