Form 4116-MHM-AA, Minor Home Modification/Adaptive Aids Summary Sheet
Effective Date: 9/2011
Providers must submit Form 4116-MHM-AA, Summary Sheet, to DADS to request reimbursement authorization for payment for minor home modifications and adaptive aids.
The same authorization for payment form may be used for:
- more than one individual; and
- any combination of adaptive aids and minor home modifications on the summary sheet.
Multiple requests for authorization for payment on the same form must have the same service month and year.
An authorization for payment form for adaptive aids and minor home modifications must also include:
- for which the program provider is requesting authorization for payment;
- the service code for the adaptive aid from Appendix VII, Billable Adaptive Aids, or the minor home modification from Appendix X, Billable Minor Home Modifications;
- the purchase amount of the adaptive aid or minor home modification; and
Mail all claims to:
Authorization for Payment
Claims Management, Mail Code W-400
Department of Aging and Disability Services
P.O. Box 149030
Austin, TX 78714-9030
The following information must be included on an authorization for payment form:
Service Month and Year — For an adaptive aid, state the calendar month and year in which the individual received the service component. For a minor home modification, state the calendar month and year in which the minor home modification was completed.
Component Code — State the component code for the program provider that provided the service component.
Contract No. — Self explanatory.
Contact Person — Enter the name of the staff member completing the form.
Area Code and Telephone No. — Enter the telephone number for the contact person during normal business hours.
Name (Last, First, Initial) — Enter the name of the individual receiving the service.
Client CARE ID No. — Enter the CARE ID number for the individual receiving the service.
Service Date (MM/DD/YY) — For an adaptive aid, enter the calendar day, month and year in which the individual received the service component. For a minor home modification, enter the calendar day, month and year in which the minor home modification was completed.
Service Description — Self explanatory.
Service Code — Self explanatory.
Dollars Spent — Self explanatory.
Req. Fee — Self explanatory.
Attestation — Signature and date of submitter certifying that all requirements of Billing Guidelines have been met. Signature must be original.