Form 4122/4122-S
Instructions

Foster/Companion Service Delivery Log

02-2012

PURPOSE

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 foster/companion care service component.

PROCEDURE

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:

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.

DETAILED INSTRUCTIONS

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.

Foster/Companion Printed Name — The service provider(s) providing the service prints his/her name.

Foster/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.