DIY HCO/PCS Forms Package

The do-it-yourself “Forms Package”, is composed of the forms provided in our California HCO Policy & Procedure Manual. They are ideal for those who do not have these manuals. If you have both this manual, you will already have these forms.


The Forms Package is only available as a group. Forms cannot be purchased individually.


There are over 100 forms written in MS Word of fillable PDF. All forms can be ready to be edited to reflect your Agency’s name and other details.


The “Forms Package” is offered in electronic format only.  

DIY HCO/PCS Forms Package

  • The following forms are included in this DIY Kit:

    Advanced Directive Information

    Agency & Independent Contractor Agreement

    Authorization to Release PHI

    Automobile Use Waiver Agreement

    Auto-Payment Authorization Form

    Bomb Threat Checklist

    Caregiver Notes-Client Daily Record

    Caregiver Notes-Weekly Notes

    Client Caregiver Activity Report

    Client Flow Chart

    Client Insurance Information

    Client Medication Record

    Client Observation Diagram

    Client Satisfaction Questionnaire

    Client Satisfaction with Implemented Services

    Client Service Certification Record

    Client Valuables

    Communication with People With Disabilities

    Competency Assessment Form

    Complaint & Grievance Form

    Confidential Payroll Information

    Confidentiality/Non-Disclosure Agreement

    Conflict of Interest Statement

    Consent for Referral & Release of Information

    Consent to Release Information – Client

    Consent to Release Information – Employee

    Coordination of Care Checklist

    COVID-19 Declination Form

    COVID-19 Employee Notice

    COVID-19 Screening Tool - Return-to-Work

    Declination of Influenza Vaccination

    Discharge or Transfer - Client Notification Form

    Discharge or Transfer - Summary

    Emergency Phone Numbers - Client

    Emergency Preparedness Plan

    Employee Contact Information

    Employee Performance Appraisal - Annual

    Employee Performance Appraisal - Supervisory Visit

    Employee Roster - Template

    Employee Roster - Tracking

    Employment Application

    Employment Candidate Interview

    FAX Coversheet

    Financial Transactions Record

    Grocery List

    HBV Consent/Waiver Form

    HBV General FACT SHEET

    HCA Introduction - Training & Skills Checklist

    Registered Home Care Aide Training Log

    Home Safety Checklist

    I-9 Employment Eligibility Verification - Form

    Identity Theft Prevention Program & Addendums

    Incident Report

    Incident Report - Medication

    Incident Report - Post Exposure to Blood-borne Diseases

    Incident Report - Post Exposure to Tuberculosis

    Incident Report: COVID-19

    Incident Reporting Log

    Job Description - Template


    Medication Log

    Mission, Vision, Values Statement

    Notice of Privacy Practices

    Notice of Receipt - NPP - Acknowledgment

    Notice to Employee - Labor Code LC 2810.5

    Notification of Affiliated Home Care Aide Status - Agency Employee

    Nursing Assessment

    Offer Letter of Employment

    On Duty Meal Period Agreement

    Orientation Checklist

    Orientation Sign in Form

    Paid Family Leave Brochure de2511

    Paid Sick Days Poster

    Payment Agreement

    Personal/Private Vehicle Mileage Form

    Personnel Record Contents - Checklist

    Personnel Record Inspection Log

    Personnel Type Change Notification to HCSB

    Policy & Procedure Change Tracking Form

    Pre-Adverse Action Notice

    Pre-Adverse pdf-0096-fair-credit-reporting-act

    Pre-Employment Background Check Authorization

    Private-Direct Hiring of HCA Agreement

    QAPI - Quality Assessment & Performance Improvement Plan

    Recurring Payment Authorization Form

    Reference Check Authorization

    Reference Check X2

    Referral Intake Form

    Release of Liability – Client Transportation

    Return of Company Property Agreement

    Rights & Responsibilities of Client & Organization

    Separation Form - AHCA

    Service Agreement & Fee Schedule

    Service Deposit

    Service Information Handout for Consumers-Clients doc

    Service Plan & Face Sheet

    Sexual Abuse Policy - Employee Acknowledgment

    Sexual Harassment - The Facts About Sexual Harassment

    Staff Record of Training

    Standards of Conduct

    Time of Hire Pamphlet - Workers' Compensation

    W-4 - IRS Employee's Withholding Allowance Certificate