Downloading a Form to Your Computer

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Effective Date: 



Updated: 8/2015


To record the individual's recoupment amount identified during the review.


When to Prepare

Complete during review.

Number of Copies

Complete one original. You may enter information for five individuals on each page. You may use additional pages if necessary.


Keep the original for your files. Give one copy to the provider agency upon request.

Form Retention

Keep the form according to the terms of the contract.

Detailed Instructions

Contract No. — Self-explanatory.

Total Recoupment — Add the recoupment amounts for all the individuals listed on the form and enter the total amount.

Completed By Enter the first and last name of the person completing the form.

Date Completed — Enter the date the review is completed.

Sample No. — Enter the sample number.

Unit No. — Enter home unit's or individual's subscriber number.

Review Month — Enter the review month.

  1. Self-explanatory. For comprehensive information, see Texas Administrative Code §52.407 System Checks, §52.417(c) Allowed Payment, §52.419(c) Payment, and §52.421 Termination.
  2. Recoupment is made if provider fails to document:
  • monthly equipment test; or
  • three attempts to conduct monthly equipment test. Written notification is submitted to the case manager by the 15th day of the month after the system check was due. Note: Written notification requirements are outlined under §52.407(c)(3); or
  • there is no equipment test prior to removal of the equipment, if services to the individual were terminated during the review month for one of the reasons cited in §52.421(a).

Note: An additional test is not required if monthly equipment test has been done in the month equipment is being removed.

The recoupment amount should be the contracted rate.

Comments — Enter any comments you may have about the fiscal monitoring review.