Follow the steps to effectively fill out the form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Input the customer name in the designated field. Ensure this is the person's full name as listed in relevant documentation.
3. Enter the prime's name in the next field, as applicable. This may refer to the primary person in the care plan.
4. Fill in the provider's name and provider number. This identifies who is delivering the services.
5. Complete the CM organization field, which pertains to the case management organization overseeing the service provision.
6. Input the service coordinator or personal agent's name responsible for the services.
7. Document the service authorized, including the modification code, units, and type.
8. Indicate the frequency of the service delivery.
9. Record the dates and times for each service delivered in the appropriate fields. Be precise with start and end times.
10. Calculate the total service units/hours and enter this in the designated total field.
11. If applicable, mark whether the services are group services.
12. Describe the service goal briefly to provide context.
13. Add any progress notes, documenting the specifics of service delivery and outcomes.
14. Ensure both the customer/employer and provider/employee sign and date the form to verify the information.
15. If necessary, authorize staff to enter data into the system by initialing the corresponding field.
16. Final review should be done before submission. Submit this completed and signed form to the relevant CDDP, Brokerage, or CIIS Program authorized for the services delivered.

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