Effective Date: 
2/2012

Documents

 

Instructions

Updated: 2/2012

 

Purpose

Form 4120 is used by staff, as well as Home and Community-based Services (HCS) and Texas Home Living Service (TxHmL) Waiver program providers to document a service claim for the Day Habilitation service component.

 

Procedure

When to Prepare

Form 4120 must be completed within a reasonable time frame after billable activities have been performed for an individual by a service provider.

Form Retention

The program provider must maintain a copy of the completed Form 4120 in the individual's record.

General Instructions

  • Form 4120 must be used for only one individual.
  • Form 4120 may be used for up to five separate billable service claims. Each billable service claim must be entered on a separate column.
  • Form 4120, 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.

 

Detailed Instructions

Individual Name — Enter the individual's name.

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

Local Case No./Client Assignment and Registration (CARE) ID — Enter the individual's local case number and CARE ID number.

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.

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.

Comments (Special Events/Occurrences) — Provide written documentation as needed or desired. If providing written documentation, enter the date in which the billable activity occurred and the staff initials.

Employee Signature — The service provider(s) who provided services during the billable activity must sign the form.

Initials — Enter the initials of the service provider(s) providing billable activities to the individual.

Staff ID — Enter the staff ID number(s) of the service provider(s).

Questions

To inquire about Form 4120 or instructions, call the Billing & Payment Hotline at 512-438-5359.

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