Form 1745 - Service Delivery Log With Written Narrative/written Summary - 2014
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1
2Texas Department of Aging
Form 1745
Consumer Directed Services
and Disability Services
August 2014-E
Service Delivery Log with Written Narrative/Written Summary
Page 1 of 2
Program
Participant Name
Pay Period
Employer Name
Service Type
Service Provider Name
PAS
SHL
Respite
Community Support
Residential Habilitation
Other
Time In
Time Out
Time In
Time Out
Total
Place of
Written Narrative
Service Date
(AM or PM)
(AM or PM)
(AM or PM)
(AM or PM)
Hours
Service
Continue narrative on next page, if needed.
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Total Hours
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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.
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
FMSA Use Only
Service Type:
$
Hours Reg at
per hour
Hours Sick
$
Hours OT at
per hour
Hours Holiday
Hours Vacation
Bonus
Other
Time sheet:
Acceptable
Unacceptable
Return to employer
Notes:
FMSA:
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