This form must be used to summarize Deaf Blind with Multiple Disabilities (DBMD) services provided to an individual in a calendar month. Exceptions:
- Licensed Assisted Living and Licensed Home Health Assisted Living and 18-Hour Assisted Living do not need to be summarized on this form.
- Services that require electronic visit verification do not need to be summarized on this form: Community First Choice Personal Attendant Services / Habilitation (CFC PAS/Hab) Services; and In-Home Respite Services.
- Services provided through the Consumer Directed Services (CDS) option do not need to be summarized on this form.
The DBMD program provider’s timekeeper uses the form to demonstrate verification of the accuracy of the information on the form prior to submitting a claim for the service.
Funds paid to the program provider for a submitted service claim may be recouped by HHSC if Form 6503 is not completed correctly or if the information documented on the form does not support the billed claim.
Each DBMD service provider will use a separate form to document the service provided to an individual. The DBMD program provider must ensure:
- Only one individual receiving DBMD services per form.
- Only one service provider per form - hours worked by two or more different service providers should not be placed on the same form.
- Only one service type per form – for example, case management cannot be on the same form as intervener services.
- Only the services provided in one calendar month per form.
- When applicable, log entries on the DBMD Summary of Services Delivered form must be accompanied by supporting documentation to account for all activities performed on the shift, for example, if a nurse completes an assessment.
Month and Year — Enter the month and year the service is provided. Only one month may be documented on each form.
Program Provider Name — Enter the name of the DBMD program provider.
Program Provider No. — Enter the nine-digit DBMD program provider number.
Individual’s Name — Enter the full name of the individual receiving the DBMD program service.
Medicaid No. — Enter the Medicaid number of the individual receiving the DBMD program service. If the form is being completed for a pre-assessment and the individual does not have a Medicaid number, enter the phrase “pending waiver eligibility.”
Birth Date — Enter the date of birth for the individual receiving the DBMD program service.
Service Provider Name — Enter the name of the service provider who provided the service documented on the form. A separate form must be completed for each service provider.
Contract with Other Agency — Check either box Yes or box No as follows:
- Yes if the service provider identified in Service Provider Name is employed by an agency other than the DBMD program provider identified above in Program Provider Name; or
- No if the service provider is employed by the DBMD program provider identified in Program Provider Name.
Name of Company (if contract with other agency) — Enter the name of the company that employs the contracted service provider if other than the DBMD program provider identified in Program Provider Name.
Authorized Service (check only one) — Check the box for the DBMD program service the service provider identified in Service Provider Name provided. A separate form must be completed for every service the individual receives.
Hours Worked — This section must be completed by the person who provides the service. For each day when a service was provided, enter the time in and time out for the service provider. Enter the time of day and include “a” for a.m., or “p” for p.m. Service providers may also document the time in and out by using military time. Example: time in – 9:00p, time out – 10:30p or time in – 2100, time out – 2230. If there is more than one time in and time out per day, the service provider must enter these times in the same line.
Total Time —Add the total amount of time that a service was provided each day and document that amount in the total time column.
Comments — This is an optional field and additional information can be documented here at the discretion of the timekeeper or service provider. Additional information may include reference s such as “case manager review” or “nursing assessment” to note the type of supporting documentation available for that service event. Justifications to explain a schedule change may also be documented in this field.
Entering information in this field does not replace the requirement to provide a description of the service activity performed.
Pay Period Total Hours — Add all daily totals and document that number in this field.
Service Provider Name — Use legible handwriting to print or type the name of the person who provided the service documented on the form.
Service Provider Signature and Date — The service provider who provided the service documented on the form signs and dates the form. The service provider must not sign and the date the form prior to providing the service.
Timekeeper Name — Use legible handwriting to print or type the name of the timekeeper signing the form. The timekeeper must be a staff person other than the service provider.
Timekeeper Signature and Date — After the service provider makes the last entry on the form, the timekeeper for the program provider must sign and date the form as verification of the accuracy of the information on the form. Verification must be completed prior to submitting a claim for the service.
Note: Claims must not be submitted for reimbursement prior to obtaining both the service provider and timekeeper signature.