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False or fraudulent time sheet could result in a Medicaid fraud referral. Signature - Service Provider Date Signature - Employer or DR CDSA Use Only Service Type: Hours Reg at $ per hour Hours Sick Hours OT at $ per hour Hours Holiday Hours Vacation Bonus Other Timesheet: Notes: Acceptable Unacceptable Return to employer CDSA: Date Texas Department of Aging and Disability Services Consumer Directed Services Form 1745 Page 2 of 2, 07/2013-E Service Delivery Log with Writt.

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