Parental Verification For Receipt Of Behavioral Services

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PARENTAL VERIFICATION FOR RECEIPT OF BEHAVIORAL SERVICES
Consumer Name:_____________________________________________
UCI#:__________________________
Authorization# ______________
Vendor Name: ______________________________________________
Vendor#: ______________________
Service Code: ______________
Vendor Phone: ______________________________________________
Service Month: _________________
Service Year:
______________
Date
Name & Credential of
Location
Service
Start
End
Total
Total
Parent Signature
(if different than consumer
(Face to Face service)
Worker
Type
Time
Time
Time
Miles
home)
Subtotals:
*Time should be rounded to the nearest ¼ hour
SERVICE TYPES:
(1) Face to Face
(2) Report Prep
(3) Meetings
(4) Phone-Client
(5) Phone – Other
(6) Other
Vendor Signature: _____________________________________________________________
Date: _______________________________________________
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