Get Oil Disposal Log Sheet

Consumer Directed Services Alamo Consumer Direct Texas Department of Aging and Disability Services Form 1745 compliant Service Delivery Log with Written Narrative/Written Summary Phone 512 420 0832 Toll Free 1 877 903 0832 Toll Free Fax 1 877 652 0877 8701 Shoal Creek Blvd Suite 303 Austin TX 78757 6809 Employee Name Consumer Name Time sheet due date If faxed or dropped off time sheets are due at the Consumer Direct office by Monday at midnight following the week of service. If mailed they must be postmarked by Monday following the week of service. Late time sheets will result in late pay. Check Program DBMD CBA CLASS HCS PCS PHC TXHML Service Date Sunday Monday Tuesday Wednesday Thursday Friday Saturday mm/dd/yy Service Code Time In Time Out Daily Total NOTE Time sheets must be signed AFTER the work is completed* Advance time sheets will not be accepted* Total Weekly Hours Place of Service Written Narrative/Summary Employee/Consumer I certify that the work hours listed above are accurate and that services were provided in accordance with the Employee Work Schedule and Assigned Tasks DADS 1731. I understand that falsification of this time sheet is considered Medicaid Fraud and may result in dismissal from the program and criminal prosecution* Employee Signature Date Consumer Signature 02052 Rev* 06/27/2013. If mailed they must be postmarked by Monday following the week of service. Late time sheets will result in late pay. Check Program DBMD CBA CLASS HCS PCS PHC TXHML Service Date Sunday Monday Tuesday Wednesday Thursday Friday Saturday mm/dd/yy Service Code Time In Time Out Daily Total NOTE Time sheets must be signed AFTER the work is completed* Advance time sheets will not be accepted* Total Weekly Hours Place of Service Written Narrative/Summary Employee/Consumer I certify that the work hours listed above are accurate and that services were provided in accordance with the Employee Work Schedule and Assigned Tasks DADS 1731. Check Program DBMD CBA CLASS HCS PCS PHC TXHML Service Date Sunday Monday Tuesday Wednesday Thursday Friday Saturday mm/dd/yy Service Code Time In Time Out Daily Total NOTE Time sheets must be signed AFTER the work is completed* Advance time sheets will not be accepted* Total Weekly Hours Place of Service Written Narrative/Summary Employee/Consumer I certify that the work hours listed above are accurate and that services were provided in accordance with the Employee Work Schedule and Assigned Tasks DADS 1731. I understand that falsification of this time sheet is considered Medicaid Fraud and may result in dismissal from the program and criminal prosecution* Employee Signature Date Consumer Signature 02052 Rev* 06/27/2013. If mailed they must be postmarked by Monday following the week of service. Late time sheets will result in late pay. Check Program DBMD CBA CLASS HCS PCS PHC TXHML Service Date Sunday Monday Tuesday Wednesday Thursday Friday Saturday mm/dd/yy Service Code Time In Time Out Daily Total NOTE Time sheets must be signed AFTER the work is completed* Advance time sheets will not be accepted* Total Weekly Hours Place of Service Written Narrative/Summary Employee/Consumer I certify that the work hours listed above are accurate and that services were provided in accordance with the Employee Work Schedule and Assigned Tasks DADS 1731. I understand that falsification of this time sheet is considered Medicaid Fraud and may result in dismissal from the program and criminal prosecution* Employee Signature Date Consumer Signature 02052 Rev* 06/27/2013.