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Form 4123 is an optional form used by staff and Home and Community-based Services (HCS) Waiver program providers to document a service claim for the Registered Nurse, Specialized Registered Nurse, Licensed Vocational Nurse and Specialized Licensed Vocational Nurse service components.
When to Prepare
Form 4123 must be completed within a reasonable time frame after billable activities have been performed for an individual by a service provider.
The program provider must maintain a copy of the completed Form 4123 in the individual's record.
- Form 4123 must be used for only one individual.
- Form 4123 must be used for only one service provider. This service provider must provide billable activities during each service claim.
- Form 4123 may be used for up to two separate billable service claims. Each billable service claim must be entered on a separate section.
- Additional supporting documentation for the Nursing Service Delivery Log is required for all service activities denoted by an asterisk (i.e., reports, assessments).
- Form 4123, or another form created for a similarly intended purpose, is considered a Medicaid document used for Medicaid purposes. As such, by using this form, you understand it is your responsibility to record accurate information, as this information may be subject to a court of law. Failure to record accurate information and/or deliberate falsification of documentation is strictly prohibited.
Individual Name — Enter the individual's name.
Local Case No./CARE ID — Enter the individual's local case number or CARE ID number.
Staff ID No. — Enter the service provider's staff ID number.
Date of Service — Enter the date (month, day, year) that the billable activity occurred.
Begin Time — Enter the time when the billable activity started.
End Time — Enter the time when the billable activity ended.
Location — Enter the location code (see location table at the bottom of the form) that corresponds to the place of service in which the billable activity occurred.
Staff Signature — The service provider who provided services during the billable activity must sign on the line that corresponds to the service event entered. Signature stamps are not permitted.
Check all services provided during a continuous time frame — Check all applicable services that correspond to activities provided by the service provider. A minimum of one service must be entered for a billable service claim to have occurred.
Non Billable Activities — Document these activities on separate sheet.
Billable Units — Enter the total billable units for the corresponding day of service.
Comments — Provide legible written documentation as needed. Written documentation could be just one or two words or additional information if needed. If providing documentation, locate the number reflected for the applicable service(s) and notate the additional information required. If documenting more medication reconciliation, other than when the medication arrives from the pharmacy, document in the comment section the med errors documented either on the MARS or by staff reporting that caused the additional reconciliation and date in which the error occurred.
Additional supporting documentation for the Nursing Service Delivery Log is required for all service activities denoted by an asterisk (i.e., reports, assessments).
To inquire about Form 4121 or instructions, call the Billing & Payment Hotline at 512-438-5359.