Get North Dakota Family Caregiver Support Program Provider Service Log-agency For Office Use Only

This guide provides a clear and comprehensive approach to completing the NORTH DAKOTA FAMILY CAREGIVER SUPPORT PROGRAM PROVIDER SERVICE LOG. Following these detailed instructions will ensure accurate submission of the required information.

Follow the steps to successfully complete the service log.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, enter the agency information, including the agency name, address, city, telephone number, and billing period. Ensure all fields are filled out clearly.
3. In Section II, input the caregiver information. Enter the caregiver's name and select the type of service provided by checking the appropriate options for respite, caregiver training, or caregiver/family counseling.
4. Record the amount and date of service. For each service instance, insert the date, start time, end time, and number of hours of service provided. Repeat this process for additional services as necessary.
5. Calculate the total amount requested per caregiver, ensuring to specify all hourly and daily rates in the respective fields. Note that payment for hourly rates cannot exceed the maximum daily rate.
6. In Section III, provide the certification and agreement details by confirming the accuracy of the information. The designated provider should sign and date the form to certify the information is true and complete.
7. Once all sections are completed, review the entire form for accuracy. You can then save changes, download the form, or print it out for submission.

Complete your forms online now to ensure timely processing and reimbursement.