Form 4121 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 Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) service component.
When to Prepare
Form 4121 must be completed within 14 calendar days after the activity being documented is provided.
The program provider must maintain a copy of the completed Form 4121 in the individual's record.
- Form 4121 must be used for only one individual.
- Form 4121 must be used for only one service provider. This service provider must provide billable activities during each service claim.
- Form 4121 may be used for up to seven separate billable service events. Each billable service event must be entered on a separate column.
- Form 4121, 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.
Individual Name — Enter the individual's name.
Local Case No. — Enter the individual's local case number.
EVV Attendant ID — Enter the service provider's Electronic Visit Verification (EVV) Attendant ID number.
Staff ID No. — Enter the service provider's staff ID number.
Date of Service — Enter the date (month, day, year) that the billable activity occurred.
Begin Time — Enter the time when the billable activity started.
End Time — Enter the time when the billable activity ended.
Total Time — Enter the total number of hours and minutes for the billable activity. If multiple individuals or service providers are involved in the billable activity, the total time must be apportioned according to CFC Billing Requirements for Home and Community-based Services and Texas Home Living Providers.
Location — Enter the location code (see location table at the bottom of the form) that corresponds to the place of service in which the billable activity occurred.
No. of Individuals — Enter number of individuals.
Staff Signature — The service provider who provided services during the billable activity must sign on the line that corresponds to the service event entered.
No. of Staff — Enter number of service providers.
Enter code for all services provided. — Enter all applicable service codes that correspond to activities provided by the service provider (see the tables at the bottom of the form). A minimum of one service code must be entered for a billable service claim to have occurred.
Billable Units — Enter the total billable units for the corresponding day of service.
Comments — Provide legible written documentation as needed or desired. If providing documentation, enter the date in which the billable activity occurred.
To inquire about Form 4121 or instructions, email email@example.com.