EPSDT PCS DAILY SCHEDULE

EPSDT PCS DAILY SCHEDULE

Client Name: _____________________

Medicaid#: _____________________

Specify hours of all services received by recipient. This includes EPSDT PCS as well as other services

such as home health aide or nurse, respite or PCA from waiver or contract, physical therapy, etc. Be

certain to show times the recipient is in school.

TIME

6:00 AM

Monday

Tuesday

7:00 AM

8:00 AM

9:00 AM

10:00 AM

11:00 AM

NOON

1:00 PM

2:00 PM

3:00 PM

4:00 PM

5:00 PM

6:00 PM

7:00 PM

8:00 PM

9:00 PM

10:00 PM

11:00 PM

12:00 PM

1:00 AM

2:00 AM

3:00 AM

4:00 AM

5:00 AM

Comments

EPSDT-PCS Daily Schedule - 3

Wednesday

Thursday

Friday

Saturday

Sunday

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