Form 8616, In-Home Individualized Skills and Socialization Service Delivery Log

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Documents

Effective Date: 2/2023

Instructions

Updated: 2/2023

Purpose

Form 8616 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 In-Home Individualized Skills and Socialization.

Procedure

When to Prepare

Form 8616 must be completed within 14 calendar days after the activity being documented is provided.

Form Retention

The program provider must maintain a copy of the completed Form 8616 in the individual's record.

General Instructions

  • Form 8616 must be used for only one individual.
  • Form 8616 may be used for multiple billable service events. Each billable service event must have a begin and end time.
  • Form 8616 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.

Detailed Instructions

Individual Name — Enter the individual's name.

Place of Service(s) — Enter the address at which the billable activity occurred.

Staff ID — Enter the Staff ID of the service provider providing a billable activity. The Staff ID must match the name of the service 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 in-home individualized skills and socialization.

Service Provider Signature — The service provider who provided the  service event for in-home 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 8616.

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.

Special Events or Occurrences (Optional) — Provide written documentation as needed or desired. 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 providing billable activities to the individual.

Questions

To inquire about Form 8616 or instructions, email HCSPolicy@hhs.texas.gov.