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Effective Date: 




Updated: 10-2004



To document the quality and appropriateness of day activity and health services (DAHS) during utilization review.


When to Prepare

The CCAD regional nurse completes Form 3062 for each DAHS client he interviews/observes at the DAHS facility during the utilization review visit.

Number of Copies

Complete one Form 3062 for each client reviewed during the utilization review visit. Complete Page 3 in triplicate.

Form Retention

The CCAD regional nurse keeps the original in the client's casefolder or agency folder for 12 months or, in the case of an appeal, until the appeal is resolved.


The regional nurse supervisor assembles one copy of Page 3 for each client in the utilization review sample in a batch at the end of the review period.

A copy of Page 3 may be provided to the provider agency for information or request for follow-up action. Additional copies of Form 3056 may be provided to the contract manager, case manager, or in the case of an appeal, the regional hearing officer.

Detailed Instructions