Minor Home Modifications, Adaptive Aids or Dental Summary Sheet

See bottom of this page for a list of handbooks sharing this appendix.

Providers must submit Form 4116-MHM-AA, Minor Home Modification/Adaptive Aids Summary Sheet, or Form 4116-Dental, Dental Summary Sheet, to the Department of Aging and Disability Services to request reimbursement authorizations for payments for minor home modifications, adaptive aids and dental services.

Click here to see form instructions.

Shared Appendix 30

This appendix appears in the following handbooks:

Home and Community-based Services Program Billing Guidelines (HCSBG): Appendix IX
Texas Home Living Program Billing Guidelines (TxHmLBG): Appendix VII