Follow the steps to complete your TX HHS 3625 form online

1. Click ‘Get Form’ button to obtain the form and open it in a suitable editor.
2. Fill in the 'Service Month and Year' at the top of the form. This will indicate the time period for which you are documenting services delivered.
3. In 'Section A – Participant Information,' enter the participant's name, Medicaid number, and Social Security number if the individual is an applicant.
4. Proceed to 'Section B – Provider Agency Information' and select the agency type. Provide the agency name and vendor number.
5. In 'Section C – Pre-Enrollment Assessment Fees,' indicate whether case management services received a full or partial assessment, and check the appropriate boxes.
6. Navigate to 'Section D – Case Management Services.' Here, enter the case manager's name and specify the case management services as ongoing.
7. In 'Section E – Direct Services,' choose a method of delivery (select only one) and enter the name of the employee or individual as applicable. Only enter one authorized service and provide the service category, service code, and bill code.
8. Record the time in 'Section F – Record of Time.' Document the day, time in, time out, units, and amount for each day services were delivered, ensuring to fill in totals.
9. In 'Section G – Certification,' obtain signatures from the person delivering the service, the participant or their guardian, and the timekeeper. Include the appropriate dates.
10. Review all entries carefully. Once completed, you can save your changes, download the form, print it, or share it as needed.

Complete your TX HHS 3625 form online today and ensure accurate documentation of services delivered.