VA SamariCare Forms

Client / Patient

Patient Information and Intake Form
New Patient Checklist
VA SamariCare - Rights to Complain v012025
LarCare Inc (VA) DBA SamariCare Client Rights v062025
LarCare Inc. VA DBA SamariCare Client / Patient Personal Care Agreement
VA SamariCare - Advance Directives v012025
COVID-19 Protocol & Policy for LarCare Inc v052025
Request For Private Pay Invoice v012025
SamariCare Services Client Non Solicitation Agreement

Caregivers / Contractors

Daily Tasksheet Report
Contractor Application v012025
Contractor Direct Deposit
VA SamariCare - Contractor Health Assessment v012025
VA SamariCare - Criminal Background Check and Sworn Statement of Affirmation v012025
VA SamariCare - Drug Test Clearance Policy for Virginia v012025
Tuberculosis Test (TB Test) January 2024
SamariCare Services Caregiver Conduct and Non Solicitation Agreement
VA SamariCare Procedures/ Handbook Acknowledgment v042025
Verification of Mailing Address, Physical Address, and Driver’s License Acknowledgment
Home Health Aide Performance Evaluation v092025

Nurses

LarCare Nurse Site Visit Report and Invoice v012025
LarCare Nurse Operational In-Home Site Visit
LarCare Non-Nurse Operational In-Home Site Visit v012025
LarCare Home Health Nurse Performance Evaluation v012025
LarCare SamariCare Services Home Care Assessment Form

Operation Team

VA Caretime Training Video Log
VA SamariCare 2025 Letterhead v012025
LarCare Pay Schedule for 2025
SamariCare Letterhead and Forms Template v012025
Background Check Result

Reports

SamariCare Virginia Vet Pay and Private Pay Reconcilation Ledger May 2024
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HR/Training/Education

VA Training Requirements ( Curriculum Included )
SamariCare Home Services Pamphlet
SamariCare Orientation Training Tracking Form v082025
SamariCare - Skills Training Check-Off List
SamariCare Emergency Preparedness Document v082025