Form 2124, Supported Home Living/Community Support Transportation Log

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Documents

Effective Date: 8/2024

Instructions

Updated: 08/2024

Purpose

Form 2124 is used by Texas Health and Human Services Commission (HHSC) staff, as well as Home and Community-based Services (HCS) and Texas Home Living (TxHmL) program providers to document a service event for the Supported Home Living or Community Support service components.

Note: An individual as defined in 26 Texas Administrative Code (TAC) Sections 262.3 and 263.3 is referred to as a person in this form.

Procedure

When to Prepare

Form 2124 must be completed within 14 calendar days after the activity being documented is provided. 

Form Retention

The program provider must maintain a copy of the completed Form 2124 in the record of the person receiving services.

General Instructions

•    Form 2124 must be used for only one person.
•    Form 2124 must be used for only one service provider. This service provider must provide billable activities during each service event.
•    Form 2124 may be used for up to ten separate billable service events. Each billable service event must be entered on a separate column.
•    Form 2124, 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 or deliberate falsification of documentation is strictly prohibited.

Detailed Instructions

Person Name — Enter the person’s name.
Service Provider Name — Enter the service provider's name.
Staff ID No. — Enter the service provider's staff ID number.
Method Used — Select the method used to calculate transportation time. Select Method A if the transportation time, number of passengers and number of service providers are the same for all  persons transported in a single trip. Select Method B if the transportation time, number of passengers and number of service providers are determined separately for each person transported in a single trip in segments that begin and end when the number of passengers or the number of service providers changes during the trip.
Date of Service — Enter the date (month, day, year) that the billable activity occurred.
Transportation Begin Time – For Method A, enter the time the first person gets on the vehicle. For Method B, enter the time in segments that begin when the number of passengers or the number of service providers changes during the trip. 
Transportation End Time — For Method A, enter the time the last person gets off the vehicle.
For Method B, enter the time in segments that ends when the number of passengers or the number of service providers changes during the trip.
Total Transportation Time — Enter the total number of hours and minutes for the billable activity. If multiple persons or service providers are involved in the billable activity, the total time must be apportioned according to the HCS Program Billing Requirements and TxHmL Program Billing Requirements.
No. of Service Providers — Enter number of service providers:
For Method A, enter the total number of service providers who provided services during the trip, including the driver of the vehicle.
For Method B, enter the number of service providers who provided services during each segment of a trip. A segment is when the number of passengers or number of service providers changes during a trip.
No. of passengers — Enter number of passengers:
For Method A, enter the total number of passengers transported during the trip.
For Method B, enter the number of passengers transported during each segment of the trip. 
Service Time — Service time must be determined using the transportation time, number of passengers and number of service providers for an entire trip (if using Method A), or for each segment of a trip (if using Method B). The formula for calculating the service time is Service Time = [No. of Service Providers X Transportation Time] ÷ No. of Passengers.
Units of Service — Enter the units of service. A unit of service for transportation as a supported home living activity is 1 hour.
Place of Departure — Enter the location where the person’s trip began.
Destination — Enter the location where the person’s trip ended.
Signature of Service Provider — Enter the service provider's signature.