Form 4119, Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log
Effective Date: 2/2012
Form 4119 is used by Department of Aging and Disability Services (DADS) staff and Home and Community-based Services (HCS) Waiver program providers to document a service claim for the Residential Support Services and Supervised Living service component.
When to Prepare
Form 4119 must be completed within a reasonable time frame after billable activities have been performed for an individual by a service provider.
The program provider must maintain a copy of the completed Form 4119 in the individual's record.
- Form 4119 must be used for only one individual.
- Form 4119 may be used for up to seven separate billable service claims. Each billable service claim must be entered on a separate column.
- Form 4119, or another form created for a similarly intended purpose, is considered a Medicaid document used for Medicaid purposes. As such, by using this form, you understand it is your responsibility to record accurate information, as this information may be subject to a court of law. Failure to record accurate information and/or deliberate falsification of documentation is strictly prohibited.
Individual Name — Enter the individual's name.
Place of Service(s) — Enter the complete address at which the billable activity occurred.
Local Case No./CARE ID — Enter the individual's local case number and CARE ID number.
Week Of — Enter the date (including the year) of the first day of the week.
Check One: — Mark either RSS or SL.
Date and Days of the Week — Enter the date (month, day, year) when the billable activity occurred.
Activities of Daily Living, Habilitation, Assisting With, Night Shift, Not in Home — Mark (initial or check) all items completed by the service provider. A minimum of one activity not under "Night Shift" must be marked for Residential Support Services and Supervised Living services. A minimum of one activity under "Night Shift" must be marked for a billable service claim to have occurred in Residential Support Services.
Staff Initials — Enter the initials of the service provider(s) providing billable activities for the corresponding day of service.
Date/Staff Initials/Comments — Provide legible written documentation as needed or desired to provide further justification of the services provided. If providing documentation, enter the date in which the billable activity occurred and the staff initials.
Employee Signature — The service provider(s) who provided the billable activity must sign the form.
Initials — Enter the initials of the service provider(s) who provided the billable activity.
Staff ID — Enter the staff ID number of the service provider.
To inquire about Form 4119 or instructions, call the DADS Billing & Payment Hotline at 512-438-5359.