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 Section G Certification This is to certify that I provided the services recorded above or that I completed all work required according to all specifications. Signature Person Delivering Service Date mm/dd/yy Signature Participant/Guardian Signature Timekeeper. 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. 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 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. 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 Section G Certification This is to certify that I provided the services recorded above or that I completed all work required according to all specifications. 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 Section G Certification This is to certify that I provided the services recorded above or that I completed all work required according to all specifications. Signature Person Delivering Service Date mm/dd/yy Signature Participant/Guardian Signature Timekeeper.