Form 4117, Supported Employment/Employment Assistance Service Delivery Log

Instructions for Opening a Form

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Effective Date
05/2022
4117.pdf (110.33 KB)

Instructions

Updated: 5/2022

Purpose

Form 4117 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) Waiver program providers to document a service event for the Supported Employment or Employment Assistance service components. 

Procedure

When to Complete

Form 4117 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 4117 in the individual's record.

General Instructions

  • Form 4117 must be used for only one individual.
  • Each billable service event must be entered on a separate row.
  • Form 4117, 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.

Detailed Instructions

Individual Name — Enter the individual's name.

Local Case No. — Enter the individual's local case number.

Dates of Service — Enter the date (month, day, year) that the billable activity occurred.

Begin Time — Enter the time that the billable activity started.

End Time — Enter the time that the billable activity ended.

Total Time — Enter the total time of services provided.

Location — Enter the location code for the location where the service was delivered.

Employee Name — Enter the name of the service provider(s) who provided the billable activity.

Employee Signature — The service provider(s) who provided the billable activity must sign the form.

Services provided code — Enter the corresponding code for the billable activity delivered.

Comments (Special Events/Occurrences) — Provide legible written documentation as needed or desired. If providing documentation, enter the date in which the billable activity occurred and the staff initials.

Billable Activities Codes and Location Code — Use codes to identify which billable activities were delivered and the location where service was delivered.

Questions

To inquire about Form 4117 or instructions, email providerfiscalcompliance@hhs.texas.gov.