Form 4120, Day Habilitation Service Delivery Log

Instructions for Opening a Form

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Effective Date
05/2022
4120.pdf (173.12 KB)
4120-s.pdf (174.29 KB)

Instructions

Updated: 5/2022

Purpose

Form 4120 is used by Texas Health and Human Services Commission (HHSC) staff, as well as Home and Community-based Services (HCS) and Texas Home Living Service (TxHmL) Waiver program providers to document a service event for the Day Habilitation service component.

Procedure

When to Prepare

Form 4120 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 4120 in the individual's record.

General Instructions

  • Form 4120 must be used for only one individual.
  • Form 4120 may be used for up to five separate billable service events. Each billable service event must be entered on a separate column.
  • Form 4120, 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.

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

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

Date and Days of the Week — Enter the date (month, day, year) when the billable activity occurred.

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

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

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.

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

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

Initials — Enter the initials of the service provider(s) providing billable activities to the individual.

Questions

To inquire about Form 4120 or instructions, email providerfiscalcompliance@hhs.texas.gov.