Form 6503, DBMD and CFC Summary of Services Delivered

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 1/2025

Instructions

Updated: 7/2024

Note: The term person in this form refers to an individual as defined in 26 Texas Administrative Code (TAC) Section 260.5.

Purpose

This form must be used to summarize Deaf Blind with Multiple Disabilities (DBMD) services provided to a person in a calendar month. Exceptions:

  • licensed assisted living, 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;
    • in-Home Respite Services;
    • nursing services provided in the person’s own home or family home such as registered nurse (RN), licensed vocational nurse (LVN), specialized RV and specialized LVN;
    • physical therapy (PT) provided in the home;
    • occupational therapy (OT) provided in the home; and   
       
  • services provided through the Consumer Directed Services (CDS) option do not need to be summarized on this form.

Note: Own home or family home does not include licensed assisted living facilities or licensed home health assisted living facilities. 

The DBMD program provider’s timekeeper uses the form to demonstrate verification of the accuracy of the information on the form before submitting a claim for the service.

Texas Health and Human Services Commission can recoup funds paid to the program provider for a submitted service claim if:

  • Form 6503 is not completed correctly; or
  • the information documented on the form does not support the billed claim.

Procedure

Each DBMD service provider will use a separate form to document the service provided to a person. The DBMD program provider must ensure:

  • Only one person receives DBMD services per form.
  • Only one service provider is listed per form. Do not place two or more different service providers hours worked 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 is listed per form.
  • When applicable, log entries on the DBMD Summary of Services Delivered form must include supporting documentation to account for all activities performed on the shift. A nurse completing an assessment is an example. 

Detailed Instructions

Month and Year – Enter the month and year the service is provided. Only document one month 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.

Person’s Name – Enter the full name of the person receiving the DBMD program service.

Medicaid No. — Enter the Medicaid number of the person receiving the DBMD program service. If the form is being completed for a pre-assessment and the person does not have a Medicaid number, enter the phrase “pending waiver eligibility.”

Birth Date – Enter the date of birth for the person 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.  
  • No if the service provider is employed by the DBMD program provider identified in Program Provider Name.

Name of Company, if they contract with other agency – Enter the name of the company that employs the contracted service provider if different than the DBMD program provider identified in Program Provider Name.

Authorized Service – Check the one DBMD program service the service provider identified in Service Provider Name provided. A separate form must be completed for every service the person receives. 

Hours Worked – This section must be completed by the provider of service. For each day 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 is 9:00p, time out is 10:30p or time in is 2100 and time out is 2230. If there is more than one time in and time out per day, the service provider must enter these times on 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 references 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 to verify the accuracy of the information on the form. Verification must be completed before submitting a claim for the service. 

Note: Claims must not be submitted for reimbursement before obtaining both the service provider and timekeeper signature.