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.
When to Prepare
Form 8616 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 8616 in the individual's record.
- 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.
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.
To inquire about Form 8616 or instructions, email HCSPolicy@hhs.texas.gov.