Appendix D: Service Record for CRS Data Reporting System

For more information please refer to the Data Reporting System User Guide.

Required Information Description

Facility Name

Provider name

Facility Number

ReHabWorks/Contract number

CRS ID Case Number

CRS assigned id case number

Facility case number

Facility assigned case or medical record number. If facility does not have such a number, repeat CRS ID case number in this field

Participant First Name

Participant first name

Participant Last Name

Participant last name

Service Authorization number

(ID purchase order)

Id purchase order (same as service authorization) number

PABI Setting

Residential or Non Residential

Service Type

See Service list

Service Description

See Service List

Service Location

See Location list

Service Location Other (Specify)

If other, specify

Service Start Date

Service date of therapy

Provided by

See Provider Type List

Total Number of Therapists

Number of therapists delivering service

Number of 15 Minute Units Delivered

Number of 15 minute units delivered

Setting type – “Individual”, “Group”, or Team

Individual, Group or Team

If Group, Enter # of Participants

If group, number of participants