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Effective Date: 




Updated: 5/2015



This form is to be used to summarize all services (except Consumer Directed Services, Licensed Assisted Living, Licensed Home Health Assisted Living and 18-Hour Assisted Living) provided to an individual receiving Deaf Blind with Multiple Disabilities (DBMD) services and Community First Choice (CFC) services in a billing period.



Each service and each service provider should be summarized on a separate form. (Example: Case management should not be on the same form as residential habilitation. Different service providers' habilitation or CFC Personal Assistance Services Habilitation (PAS/HAB) hours should not be placed on the same form.) Log entries on the DBMD Summary of Services Delivered form must be accompanied by supporting documentation to account for all activities performed on the shift.


Detailed Instructions

Month and Year — Insert the month and year the service is provided.

Program Provider Name — Insert the name of the DBMD/CFC provider agency.

Program Provider No. — Insert the nine-digit DBMD/CFC program provider number.

Individual's Name — Insert the full name of the applicant/individual receiving DBMD or CFC services.

Medicaid No. — Insert the Medicaid number of the individual. If the form is being completed for a pre-assessment and the individual does not have a Medicaid number, insert the phrase "pending waiver eligibility."

Birth Date — Insert the individual's date of birth.

Service Provider Name — Insert the name of the service provider who provided the service.

Contract with Other Agency — Mark the Yes box if the service was provided through an agency under contract with the DBMD provider.

Name of Company — Insert the name of the company.

Authorized Service — Check the box to signify which service was provided to the DBMD/CFC individual. Only one box should be selected.

Hours Worked — For each day when a service was provided, enter the time in and time out of the service provider. Enter the time of day (space) and a or p for a.m. or p.m. Example: time in – 9:00 a, time out – 10:30 a. If there is more than one time in and time out per day, place these times in the same line. Completing time in and time out is not required if the attached service provider time sheets have the time in and time out already completed.

Total Time — Add all times for the day, and fill in the total in the column total time.

Comments — Comments is an optional field which can be entered at the discretion of the timekeeper or service provider.

Pay Period Total Hours — Add all daily totals and place this number in this field.

Service Provider Name — Enter the name of the service provider signing the form.

Service Provider Signature — The service provider providing the service signs the form.

Timekeeper Name — Enter the name of the timekeeper signing the form.

Timekeeper Signature — The timekeeper for the agency signs the form. The timekeeper should verify the accuracy of the total hours.