Waiver Documentation for HOMEMAKER/PERSONAL CARE …



Waiver Documentation for HOMEMAKER/PERSONAL CARE SERVICES 5123:2-9-30Waiver Recipient: Provider Name: Service Location: Medicaid #: Provider #: County: Summit*Staffing ratio is 1:1 (staff to recipient) unless otherwise noted*All services provided in the home (service location) unless otherwise notedMonth/Year: *All services are routine HPC unless noted otherwise Initial boxes when services are provided or write: A-Absent, S-Sick, R-RefusedServices DescriptionIdentify Frequency and Duration12345678910111213141516171819202122232425262728293031Waiver Documentation for HOMEMAKER/PERSONAL CARE SERVICES 5123:2-9-30Waiver Recipient: Provider Name: Service Location: Medicaid #: Provider #: County: SummitMonth/Year: *Staffing ratio is 1:1 (staff to recipient) unless otherwise notedHPC routine: Office staff will fill in units: Billing per 15 minutesDate12345678910111213141516171819202122232425262728293031Start TimeEnd Timestaff#HPC UnitsHPC routine:Date12345678910111213141516171819202122232425262728293031Start TimeEnd Timestaff#HPC UnitsBilling On site On Call Rate (OSOC): typically Midnight *12am-8amDate12345678910111213141516171819202122232425262728293031Start TimeEnd Timestaff#OSOC UnitsWaiver Documentation for HOMEMAKER/PERSONAL CARE SERVICES 5123:2-9-30Waiver Recipient: Provider Name: Service Location: Medicaid #: Provider #: County: Summit*Staffing ratio is 1:1 (staff to recipient) unless otherwise noted*All services provided in the home (service location) unless otherwise notedMonth/Year: *All services are routine HPC unless noted otherwise Observations/Comments/Unusual Occurrences-UIR/MUI written/Service Refusals/Absences/Location changes/Ratio Changes/Use of On Site-On Call or Emergency Level One ServicesDATE InitialsEntry:I certify that I provided the services as noted in this record in accordance with this waiver recipient’s ISP.Signature: Initials: Signature: Initials: Signature: Initials: Signature: Initials: Signature: Initials: Signature: Initials: ................
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