HOME HEALTH AGENCY QUARTERLY REPORT
For the Quarter July 1 to September 30, 2008
Send an e-mail with this information to firstname.lastname@example.org by 5 p.m. on Wednesday, October 15,
2008 to avoid a $5,000 fine.
NAME OF HOME HEALTH AGENCY _____________________________________________________
STREET ADDRESS & CITY: __________________________________________________________
On September 30, 2008, there were ______ insulin-dependent diabetic patients receiving insulin injection
services from my home health agency.
On September 30, 2008 there were ______ patients receiving home health services from my home health
agency AND licensed hospice services.
On September 30, 2008, there were a total of ______ patients receiving home health services from my home
The following professional nurses (RNs or LPNs), whose primary job responsibility is to provide home health
services to patients, received remuneration from my home health agency in excess of $25,000 between July 1,
2008 and September 30, 2008.
Name Florida License Number
Insert additional names and license numbers if necessary.