Form 4118 is used by staff, as well as Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Waiver program providers to document a service claim for the Respite service component.
When to Complete
Form 4118 must be completed within a reasonable time frame after billable activities have been performed for an individual by a service provider.
The program provider must maintain a copy of the completed Form 4118 in the individual's record.
- Form 4118 must be used for only one individual.
- Form 4118 must be used for only one service provider.
- Form 4118 may be used for up to three separate billable service claims on one calendar day. Each billable service claim must be entered on a separate column.
- Form 4118, or another form created for a similarly intended purpose, is considered a Medicaid document used for Medicaid purposes. As such, 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 and/or deliberate falsification of documentation is strictly prohibited.
Individual Name — Enter the individual's full name.
Place of Service(s) — Enter the complete address at which the billable activity occurred.
Local Case No./CARE ID — Enter the individual's local case number and CARE ID number.
Date — Enter the date (month, day, year) that the billable activity occurred.
Mark (initial or check) all areas in which you provided assistance to the person — Mark the box that corresponds to activities provided by the service provider. The services marked must justify amount of time spent providing services. A minimum of one activity must be marked for a billable service claim to have occurred.
Time In — Enter the time when the billable activity started.
Time Out — Enter the time when the billable activity ended.
Comments (Special Events/Occurrences) — Provide legible written documentation as needed or desired to provide further justification of the services provided. If providing documentation, enter the complete date in which the billable activity occurred and the staff ID number.
Employee Signature — The service provider who provided services during the billable activity must sign in the signature box.
Initials — Enter the initials of the service provider who signed.
Staff ID — Enter the service provider's staff ID number.
To inquire about Form 4118 or instructions, call the Billing & Payment Hotline at 512-438-5359.