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EXPRS Plan of Care - Service Delivery Report Form Customer Name Prime Month Provider Name CDDP/Brokerage Resource Connections of Oregon Service Authorized Units Service Delivered On 1st-15th Date Year SC/PA Name Time Period Start/Time IN End/Time OUT AM PM Page 1 Type or Total Hours Frequency 16th-end of month of Clients SERVICE GOAL PROGRESS NOTES attach additional pages as needed RECIPIENT/EMPLOYER VERIFICATION I affirm that the data reported on this form is for actual dates/time worked by the provider delivering the service/supports listed to the recipient that it does not exceed the total amount of service authorized for the recipient and was delivered according to the recipient s service plan and provider/recipient service agreement. Customer Employer or Employer Rep Signature PROVIDER/EMPLOYEE VERIFICATION delivered according to the recipient s service plan and provider/recipient service agreement. I further acknowledge that reporting dates/time I worked in excess of the amount of service authorized for me or not consistent with the recipient s service plan may be considered Medicaid Fraud. Provider/Employee Signature I authorize CDDP/Brokerage staff to enter the data reported on this from into eXPRS on my behalf for claims creation and payment. provider initials. CDDP/BROKERAGE REVIEW This service delivery report has been reviewed and is consistent with the recipient s service plan and authorized service limits. Customer Employer or Employer Rep Signature PROVIDER/EMPLOYEE VERIFICATION delivered according to the recipient s service plan and provider/recipient service agreement. I further acknowledge that reporting dates/time I worked in excess of the amount of service authorized for me or not consistent with the recipient s service plan may be considered Medicaid Fraud. I further acknowledge that reporting dates/time I worked in excess of the amount of service authorized for me or not consistent with the recipient s service plan may be considered Medicaid Fraud. Provider/Employee Signature I authorize CDDP/Brokerage staff to enter the data reported on this from into eXPRS on my behalf for claims creation and payment. Provider/Employee Signature I authorize CDDP/Brokerage staff to enter the data reported on this from into eXPRS on my behalf for claims creation and payment. provider initials. CDDP/BROKERAGE REVIEW This service delivery report has been reviewed and is consistent with the recipient s service plan and authorized service limits. Customer Employer or Employer Rep Signature PROVIDER/EMPLOYEE VERIFICATION delivered according to the recipient s service plan and provider/recipient service agreement. I further acknowledge that reporting dates/time I worked in excess of the amount of service authorized for me or not consistent with the recipient s service plan may be considered Medicaid Fraud. Provider/Employee Signature I authorize CDDP/Brokerage staff to enter the data reported on this from into eXPRS on my behalf for claims creation and payment.

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Keywords relevant to Delivery Report

  • affirm
  • SC
  • Providers
  • brokerage
  • medicaid
  • verification
  • recipient
  • exceed
  • provider
  • Resource
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