Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to access the form and open it in the designated online editor.
2. Enter the consumer's name in the designated field, ensuring proper spelling and capitalization.
3. Complete the provider's name and address fields. Verify all details for accuracy.
4. Input the provider number, Medicaid number, and resident number in their respective fields.
5. Record the time in and time out, making sure to use the correct format (e.g., 700A for 7:00 AM).
6. Indicate the number of individuals sharing supports in the designated section, such as 1:2 if applicable.
7. Fill out the supports in plan, duration, and frequency sections by accurately describing the level and type of support provided.
8. Complete the service month and year, ensuring that the date matches the month of service being reported.
9. Use the comments section to provide any necessary staff comments, ensuring clarity in communication about service details or issues encountered.
10. Sign and date the form as required, ensuring all staff initials and signatures are completed accurately.
11. Review the entire form for any errors or missing information before saving it.
12. Once all information is confirmed as correct, save changes to the document. You can then download, print, or share the form as needed.

Complete your documents online today to ensure timely and accurate reporting.