Last Updated: August 14, 2009

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	Minimum Data Set
	Hospital In The Home (HITH)Services
	Victorian HITH Subcontracting Information
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Your Name
Contact Phone Number
Contact email
Name of Hospital
Do you take referral	Yes	No
If Yes, Do you require that your hospital retain responsibilty	Yes	No
Additional Comment
Hours of Service
Which pumps do you use?
What venous access devices do you manage
Do you have a standard service agreement	Yes	No
What are your rates / fee?
Do you have after hours on call?	Yes	No
Additional Comment
Geographic Area covered
Speciality / patient groups
Contact Person
Telephone Number
Fax
Email