Form 4118, Respite Service Delivery Log

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Effective Date
05/2022
4118.pdf (212.78 KB)

Instructions

Updated: 5/2022

Purpose

Form 4118 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 Respite service component.

Procedure

When to Complete

Form 4118 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 4118 in the individual's record.

General Instructions

  • Form 4118 must be used for only one individual.
  • Form 4118 must be used for only one service provider.
  • Form 4118 may be used for up to three separate billable service events on one calendar day. Each billable service event must be entered on a separate column.
  • Form 4118, 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 full name.

Place of Service(s) — Enter the complete address at which the billable activity occurred.

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

Date — Enter the date (month, day, year) that the billable activity occurred.

Mark (initial or check) all areas in which you provided assistance to the person — Mark the box that corresponds to activities provided by the service provider. The services marked must justify amount of time spent providing services. A minimum of one activity must be marked for a billable service claim to have occurred.

Time In — Enter the time when the billable activity started.

Time Out — Enter the time when the billable activity ended.

Employee Signature — The service provider who provided services during the billable activity must sign in the signature box.

Comments (Special Events/Occurrences) — Provide legible written documentation as needed or desired to provide further justification of the services provided. If providing documentation, enter the complete date in which the billable activity occurred and the staff ID number.

Questions

To inquire about Form 4118 or instructions, email providerfiscalcompliance@hhs.texas.gov.