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  • Tx Hhs 3625 2003

Get Tx Hhs 3625 2003

Texas Dept. of Aging and Disability Services Form 3625 February 2003 Community Living Assistance and Support Services Documentation of Services Delivered 1. Service Month and Year Section A Participant Information 2. Participant Name 3. Medicaid No* 4. Social Security No* for applicants only Section B Provider Agency Information 5. Agency Type CMA 6. Agency Name 7. Vendor No* DSA Section C Pre-Enrollment Assessment Fees CMA/DSA 8. Case Management Services Full Assessment 9. DSA Services Partial Assessment Section D Case Management Services 10. Case Manager Name Ongoing Section E Direct Services 12. Method of Delivery check only one Employee Name of employee Personal Service Agreement Name of Individual Contract with Another Agency Name of Individual and Company Direct Purchase Use only for service codes 15 and 16 13. Authorized Service Enter only ONE service. Service Category Service Code Bill Code Comments Section F Record of Time DAY TIME IN-TIME OUT/UNITS/AMOUNT Total Units/Amount S....

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Related content

Form 3625, CLASS/CFC - Documentation of Services...
— Enter the nine-digit vendor number assigned by the Texas Health and Human Services...
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AMERICAN INDEPENDENT INSURANCE COMPANY 716.105 I 1.1.doc - Area-lavoro 716-103 IBC V2.1.doc - Area-lavoro Ch%2fdateien%2fFormulare%2fPDF%2fI%2f716-103_i_V2 Hicaps Provider Add

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Mail: HHSC, PO Box 14600, Midland, TX 79711-4600. OR to your local benefits office. Call 2-1-1 to get the address. Fax: 1-877-447-2839.

800-436-6184.

Call 2-1-1 or 877-541-7905 (after you pick a language, press 2)

Call 2-1-1 or 1-877-541-7905.

HHS works with federally qualified health clinics, medical associations, community partners and local governments to help clients find the health care they need. Aging and Disability Resource Centers can help Texans find personal care, nursing care, help at home and other long-term care services.

You can also send us copies by: Fax: 1-877-447-2839 (toll-free).

800-436-6184.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
TX HHS 3625
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