Form 8615 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 on-site and off-site individualized skills and socialization.
When to Prepare
Form 8615 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 8615 in the individual's record.
- Form 8615 must be used for only one individual.
- Form 8615 may be used for multiple billable service events. Each billable service event must have a begin and end time.
- Form 8615 is considered a Medicaid document used for Medicaid purposes. 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 or deliberate falsification of documentation is strictly prohibited.
Individual Name — Enter the individual's name.
Place of Service(s) — Enter the address at which the billable activity occurred.
Level of Need — Enter the individual’s level of need.
Name of Individualized Skills and Socialization Provider — Enter the name of the entity.
Individualized Skills and Socialization Provider License Number — Enter the license number of the individualized skills and socialization provider.
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.
Name of Service Provider — The printed name of the service provider who provided the service event for on-site or off-site individualized skills and socialization.
Service Provider Signature — At least one service provider who provided the service event for on-site or off-site individualized skills and socialization must sign the form. If more than two service events occur in a calendar day, the service provider must complete a new Form 8615.
Initial all areas in which you assisted the person — Initial the box that corresponds to activities provided by the service provider. The services initialed must justify amount of time spent providing services. A minimum of one activity must be marked for a billable service claim to have occurred.
Community Locations Visited and Special Events or Occurrences — This field is required to identify the location(s) for off-site individualized skills and socialization and may be used to document special events or occurrences. If providing written documentation, enter the date on which the billable activity occurred and the staff initials.
Initials — Enter the initials of the service provider(s) providing billable activities to the individual.
To inquire about Form 8615 or instructions, email firstname.lastname@example.org.