Form 8605, Documentation of Completion of Purchase

Effective Date
05/2015
Document
Document
8605.pdf (116.03 KB)

Instructions

Updated: 5/2015

Purpose

This form is used by the following programs:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf-Blind with Multiple Disabilities (DBMD)
  • Medically Dependent Children Program (MDCP)
  • Community First Choice (CFC) option for Emergency Response System (ERS) only

The form serves as the primary document for purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals. Service providers use this form for the following services:

  • Adaptive Aids (AA)
  • Minor Home Modifications (MHM)
  • Medical Supplies (MS) (not applicable for MDCP)
  • ERS (applicable only to CFC option)

Procedure

When to Prepare

The service provider representative completes Section I after the AA/MS or CFC ERS has been delivered or after the MHM has been completed to assess the individual's satisfaction, to identify any need for additional orientation/training hours and to document the individual's recommendations for resolution if dissatisfied with the purchase or with the modification.

For DBMD, this section does not need to be completed for batteries purchased.

The service provider representative completes Section II after the adaptive aid, medical supply or CFC ERS has been delivered to determine if the adaptive aid, medical supply or CFC ERS meets the individual's needs and, if applicable, upon resolution of problems that previously kept the adaptive aid, medical supply or CFC ERS from meeting the individual's documented needs. This section is also completed after the minor home modification has been completed.

An inspector completes Section III upon completion of every minor home modification and, if applicable, upon resolution of minor home modifications that previously did not meet Texas Accessibility Standards requirements or specifications. The inspector cannot be the same person who provided the minor home modification.

If the individual is not satisfied with the AA/MS/MHM or CFC ERS, this form should be submitted again once the resolution has been completed.

Number of Copies

Complete one original for each AA/MS/MHM or CFC ERS.

For CLASS and MDCP, provide a copy of the form to the case manager.

Transmittal

The service provider retains the original Form 8605 with all fields completed.

For CLASS, the service provider sends a copy to the case manager within seven workdays of verifying that the adaptive aid, medical supply or CFC ERS was delivered or that the minor home modification was completed and the individual's satisfaction was assessed.

Form Retention

Retain this form according to the terms in the appropriate waiver handbook (if applicable).

Detailed Instructions

Note: Financial recoupment may result if Form 8605 is not completed.

Service Provider — Enter the name of the service provider.

Vendor No. — Enter the service provider's vendor/contract number.

Individual Name — Enter the individual's name.

Type of Purchase — Mark the type of service: Adaptive Aid/Medical Supply, CFC ERS or Minor Home Modification.

Completion Date — Enter the date the adaptive aid/medical supply, CFC ERS was delivered or the minor home modification was completed.

Individual Address — Enter the individual's physical address, including city, state and ZIP Code.

Description of AA/MS/MHM — Enter the specific description of the AA/MS/MHM or CFC ERS.

Invoice Cost of Item — The amount entered here must not exceed the approved cost.

Type of Contact:

Home Visit — Mark the home visit box indicating that a home visit was conducted.

Telephone Contact — Mark the telephone box indicating that the person was contacted by telephone.

Name of Person Contacted/Relationship to Individual — Enter the name of the person contacted by telephone and their relationship to the individual.

Date of Contact — Enter the date the contact was made.

Section I — Individual Satisfaction

This section assesses the individual's level of satisfaction with the AA/MS/MHM or CFC ERS, and indicates whether additional training or orientation is needed. The service provider representative who does a home visit or calls the individual or legally authorized representative (LAR) to assess the individual's level of satisfaction after the adaptive aid, medical supply or CFC ERS has been delivered or the minor home modification has been completed must complete this section. Individual satisfaction may not be assessed by the same person who is performing the home modification inspection.

The service provider representative assists the individual/LAR to indicate satisfaction or dissatisfaction by marking the appropriate box(es).

I am satisfied with the AA/MS/MHM. — Mark this box if the individual/LAR expresses satisfaction with the AA/MS/MHM.

I am not satisfied with the AA/MS/MHM. Explain why and document recommendation(s) for resolution: — Mark this box if the individual/LAR indicates dissatisfaction with the AA/MS/MHM. Enter the stated reason for dissatisfaction and the individual's recommendation(s) for resolution. Attach additional pages, if needed.

I have received orientation/training in it use and do not require additional training. — Mark this box if the individual/LAR verbalizes that they have received orientation/training in the use of the AA/MS/MHM.

I am satisfied with the AA/MS/MHM, but I need more training in its use. Document additional orientation/training needed and hours required: — Mark this box if the individual/LAR expresses satisfaction with the AA/MS/MHM, but needs more training in its use. Enter the number of hours of additional orientation/training the individual requests. Attach additional pages, if needed.

I am satisfied with CFC ERS. — Mark this box if the individual/LAR expresses satisfaction with CFC ERS.

I am not satisfied with CFC ERS. Explain why and document recommendation(s) for resolution: — Mark this box if the individual/LAR indicates dissatisfaction with CFC ERS. Enter the stated reason for dissatisfaction and the individual's recommendation(s) for resolution. Attach additional pages, if needed.

I have received orientation/training in it use and do not require additional training. — Mark this box if the individual/LAR verbalizes that they have received orientation/training in the use of the CFC ERS.

I am satisfied with ERS, but I need more training in its use. Document additional orientation/training needed and hours required: — Mark this box if the individual/LAR expresses satisfaction with ERS, but needs more training in its use. Enter the number of hours of additional orientation/training the individual requests. Attach additional pages, if needed.

For CLASS and DBMD: The individual's Service Planning Team (SPT) should respond to this request by adding the appropriate number of units to the Individual Plan of Care (IPC) and Individual Program Plan (IPP) so additional orientation/training can be provided as soon as possible. This does not apply to MDCP.

Signature – Individual/LAR and Date — If a home visit was conducted, the individual/LAR signs and dates the form.

Signature – Service Provider Representative and Date — The service provider representative signs and dates the form after completing the fields.

Section II — AA/MS/MHM or CFC ERS — Service Provider Determination (Documentation of Individual's Needs)

The service provider representative marks the appropriate box.

The item meets the documented need(s) of the individual. — Mark this box if the item meets the documented needs of the individual.

The item does not meet the documented needs of the individual. Explain why and document recommendation(s) for resolution: — Mark this box if the item does not meet the needs of the individual. Document why the item does not meet the individual's needs. Attach additional pages, if needed.

CFC ERS meets the documented need(s) of the individual. — Mark this box if the item meets the documented needs of the individual.

CFC ERS does not meet the documented needs of the individual. Explain why and document recommendation(s) for resolution: — Mark this box if the item does not meet the needs of the individual. Document why the item does not meet the individual's needs. Attach additional pages, if needed.

Signature – Service Provider Representative and Date  — The service provider representative (or nurse or therapist, if applicable) who determines if the adaptive aid meets the needs of the individual must sign and date the form.

Note: The item cannot be billed until after the date it has been determined that the item is appropriate for the individual and meets the documented needs of the individual.

Section III — Minor Home Modification Inspection/Texas Accessibility Standards

The inspector marks the appropriate box (as applicable).

Modification(s) completed according to Texas Accessibility Standards requirements — no specifications were required. — Mark this box if the modification was completed according to Texas Accessibility Standards requirements and no specifications were required.

Modification(s) completed according to Texas Accessibility Standards requirements and specifications. — Mark this box if the modification was completed according to Texas Accessibility Standards requirements and the specifications provided by the agency.

Modification(s) not completed according to Texas Accessibility Standards requirements and/or specifications. Document reason(s) — Mark this box if the modification was not completed according to Texas Accessibility Standards requirements and provider specifications. The inspector must enter the reason that Texas Accessibility Standards requirements and/or provider specifications were not met. Enter any reasons in this section or provide reasons on an attachment.

The items cannot be billed until either the first or second boxes in this section have been marked. The service provider cannot bill HHSC for the modification until the inspector certifies the completed modification meets the Texas Accessibility Standards requirements and specifications.

Name of Inspector — Enter the name of the inspector.

Qualifications — List the inspector's qualifications. If additional space is required, provide an attachment.

Signature – Inspector and Date — The inspector must sign and date when the inspection is complete, even if the modification does not meet Texas Accessibility Standards requirements and specifications.

If the minor home modification does not meet Texas Accessibility Standards requirements and/or specifications, the service provider representative and individual must document the plan for resolution. The service provider representative, in consultation with the inspector, if necessary, will detail the plan for resolution.

Signature – Individual/LAR and Date — The individual/LAR must sign and date this section of the form.

Signature – Service Provider Representative, Title and Date — The service provider representative must sign and date this form and provide their title.