- To document the tasks and units of service provided.
- To provide information for billing.
When to Prepare
The provider agency makes entries to Part I of the form on each day services are delivered and completes Part II at the end of each month of service delivery.
Number of Copies
Complete in triplicate.
The original is retained by the provider agency.
The provider agency and HHSC staff retain Form 2239 for three years and 90 days after service is terminated.
Client Name — Enter the client’s name.
Client No. — Enter the client’s Medicaid or Social Security Number.
Month/Year — Enter the month and year that the services were provided.
Agency Name — Enter the name of the agency providing services.
Contract/Agreement No. — Enter the unique contract or agreement number.
Source of Referral — Check the appropriate referral source.
Type of Service — Check the type of respite care services provided.
Date — Enter each date services were delivered.
Hours per Task — (Applicable only to home care attendant and sitter services.) Enter the number of hours that were provided for each listed task on the date entered.
Total Hours — Enter the total number of hours of service provided on the date entered.
Conversion to Billing Units — For services provided by a home care attendant or sitter: Enter the number of hours of service provided on the date entered. For example, if a client received services from 10 a.m. until 4 p.m. on 9/06, enter “6 hours.” If a client received services from 7 a.m. on 9/06 until 6 p.m. on 9/07, enter “17 hours” for 9/06 and “18 hours” for 9/07.
For services provided in an adult day health care facility: For each day of service, convert number of hours of service received to half-day units. One unit is at least three hours up to (but not including) six hours. Six or more hours is two units. For example, if a client received services in an adult day health care facility from 7 a.m. until 11 a.m. on 9/06, enter “one unit.” If a client received services from 7 a.m. until 5 p.m. on 9/06, enter “two units.”
For service provided in nursing homes, hospitals, personal care homes, and adult foster homes: Enter “1 day” for each day of service delivered from midnight to midnight regardless of the number of hours of service provided during that time period. For example, if a client received respite care services in a nursing home from 6 p.m. on 9/06 until 1 p.m. on 9/10, “1 day” is entered for each of the following dates: 9/06, 9/07, 9/08, 9/09, and 9/10.
Signature and Date — Client — The client or his representative signs and dates the form, certifying that services were received.
Total No. of Units — Total the entries in the “Conversion to Billing Units” section, and enter the sums on the appropriate line(s).
Unit Rate — Enter the unit rate for each type unit of service provided. Amount Multiply “Total No. of Units” by the “Unit Rate,” and enter the product.
Total Cost — Add all entries in “amount” column and enter the sum.
Signature and Date — Agency Rep. — An agency representative signs and dates the form, certifying that services were provided as recorded on the form.