Form 1745 - Service Delivery Log With Written Narrative/written Summary - 2015

Texas Department of Aging and Disability Services

Form 1745 August 2015

Service Delivery Log with Written Narrative/Written Summary

Consumer Directed Services -

Program (CHECK ONE) ____ CLASS

____ DBMD

____ CBA/STAR+PLUS WAIVER

____ HCS

____ MDCP

Participant Name

____ non-CBA/STAR+PLUS

____ PCS

____ PHC/FC/CAS

____ TxHmL

____ PRIVATE PAY

Pay Period

Employer Name

Service Type: (Check One) ____PAS

____ PAS/HAB

____ HABILITATION

____ PROTECTIVE SUPERVISION

____ LVN NURSING

Service Provider Name

____ RN NURSING

____ RESPITE _____ TRANSPORTATION ____ OTHER: __________________________________________

Service Date

Time In

Time Out

Time In

Time Out

Total

Place of

Written Narrative

(AM or PM)

(AM or PM)

(AM or PM)

(AM or PM)

Hours

Service

Continue narrative on next page, if needed.

Total Hours

The employer cannot submit a time sheet to the Financial Management Services Agency (FMSA) for time worked by the employee while the individual was in the hospital, nursing facility, ICF/IID, or ineligible for Medicaid.

The employee and employer certify that the information provided above is complete and accurate and understand that submitting a false or fraudulent time sheet could result in a Medicaid fraud referral.

Signature — Service Provider

Date

Signature — Employer or Designated Representative (DR)

Date

Service Type:

Hours Reg at

$

per hour

Hours Sick at

$

per hour

FMSA Use Only

Hours OT at

$

per hour

Hours Holiday at

$

per hour

Hours Vacation

per hour

Bonus

$

$

Other

$

Time sheet:

Acceptable

Unacceptable

Return to employer

Notes:

FMSA: