Form 4122, Host/Companion Service Delivery Log
Effective Date: 4/2014
English PDF: 4122.pdf
Spanish PDF: 4122-S.pdf
Form 4122 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 host home/companion care service component.
When to Prepare
Form 4122 must be completed within a reasonable time frame if billable activities have been performed for an individual by a service provider. Form 4122:
- must be used for only one individual;
- may be used for up to seven separate billable service claims (each billable service claim must be entered on a separate line); and
- is considered a Medicaid document used for Medicaid purposes.
It is important to record accurate information on Form 4122, as this information may be subject to a court of law. Failure to record information and/or deliberate falsification of documentation is strictly prohibited.
Number of Copies and Form Retention
The program provider must maintain a copy of the completed form in the individual's record. For questions or assistance completing Form 4122, call the DADS Billing and Payment Hotline at 512-438-5359.
Individual Name — Enter the individual's name.
Location — Enter the address where 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 of the first day of the week.
Date and Days of the Week — Enter the date (month, day, year) when the billable activity occurred.
Activities of Daily Living, Habilitation, Assisting With, Not in Home — Mark (initial or check) all items completed by the service provider.
Date, Initials and Comments — Enter the date, initials of the service provider(s) providing billable activities to the individual and any comments. When providing comments/documentation, enter the date that the billable activity occurred.
Host/Companion Printed Name — The service provider(s) providing the service prints his/her name.
Host/Companion Staff Signature — The service provider(s) who provided the billable activity must sign the form.
Staff ID No. — Enter the identification number of the service provider.