VR2888 Diabetes Self-Management Education Assessment



Texas Workforce CommissionVocational Rehabilitation ServicesDiabetes Self-ManagementEducation Assessment FORMTEXT Instructions FORMTEXT ?Complete all appropriate fields. Boxes not marked indicate it does not apply to this customer. FORMTEXT ? Develop education and support plan in the “overall recommendations” section.Set behavior change goal for next visit. FORMTEXT ?As appropriate, you may use the following abbreviations: NA for “not applicable”, ND for “not disclosed by customer”, or NE for “not evaluated”. FORMTEXT ?Customer Information FORMTEXT ?Customer name: FORMTEXT ?????TWS-VRS Case ID: FORMTEXT ?????Referral date: FORMTEXT ?????Counselor name: FORMTEXT ?????Service authorization number: FORMTEXT ?????Customer Demographics FORMTEXT ? Age: FORMTEXT ?????Sex: (check box): FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX FMarital status: FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Single FORMCHECKBOX WidowedNumber in household (including customer): FORMTEXT ?????Physician name, specialty, and contact information handling Diabetes Management: FORMTEXT ?????Primary and secondary insurance (if applicable): FORMTEXT ?????Can customer meet diabetes-related expenses (e.g. nutritional needs, medications, test strips)? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, enter explanation and/or comments: FORMTEXT ?????Community resources used by customer: FORMTEXT ?????Support System FORMTEXT ?Primary support person and relationship: FORMTEXT ?????Telephone number:( FORMTEXT ???) FORMTEXT ?????Does the customer have disability assistance available when needed? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer currently receive home health services? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer belong to and/or attend any diabetes or disability support groups? FORMCHECKBOX Yes FORMCHECKBOX NoDiabetes History FORMTEXT ? Diabetes: FORMCHECKBOX Type 1 FORMCHECKBOX Type 2 FORMCHECKBOX Gestational Duration: FORMTEXT ????? yearsHas the customer participated in formal diabetes education in the past? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, when? FORMTEXT ?????Does the customer understand the pathophysiology of diabetes? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer have any of the following lifestyle or risk factors? FORMTEXT ?(Please report any risk factors that may affect the customer’s ability to participate in rehabilitation training to the VRC or OIB Worker directly.) FORMTEXT ? FORMTEXT ? FORMCHECKBOX Family history of diabetes FORMCHECKBOX Over age 45 FORMCHECKBOX Unhealthy alcohol consumption FORMCHECKBOX Smoking FORMCHECKBOX High blood pressure FORMCHECKBOX ObesityCustomer’s height: FORMTEXT ????? Customer’s weight: FORMTEXT ????? lb.Does the customer currently have or has been told he or she is at high risk for any of these complications? FORMTEXT ? FORMCHECKBOX Foot problems FORMCHECKBOX Neuropathy FORMCHECKBOX Renal problems FORMCHECKBOX Cardiovascular problems FORMCHECKBOX Other complications (describe): FORMTEXT ?????Has the customer been to the emergency room or hospitalized in the last 6 months? FORMCHECKBOX Yes FORMCHECKBOX No If yes, explain: FORMTEXT ?????Diabetes Self-Management Education Assessment FORMTEXT ?Vocational Rehabilitation (for VR customers only) FORMTEXT ? FORMTEXT ?What is the customer’s previous occupation? FORMTEXT ?????What is the customer’s current occupational goal? FORMTEXT ?????Has the customer ever missed work or school because of diabetes? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer need frequent breaks for self-care at work? FORMTEXT ? FORMCHECKBOX Yes, for frequent snacks and meals FORMCHECKBOX Yes, for monitoring FORMCHECKBOX Yes, for medication FORMCHECKBOX NoIs the customer able to monitor his blood sugar independently? FORMTEXT ? FORMCHECKBOX Yes, with audio meter FORMCHECKBOX Yes, with non-audio meter FORMCHECKBOX No, but wants training to be independent FORMCHECKBOX No, is unwilling or unable to monitor independentlyDoes the customer understand diabetes-related impact on employment? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No, but customer is ready to learn FORMCHECKBOX No, and customer is unwilling or unable to learnDoes the customer have a plan for discussing his or her diabetes with people at work? FORMTEXT ? FORMCHECKBOX Yes, customer is comfortable sharing information about diabetes and managing it in front of co-workers FORMCHECKBOX Yes, customer understands the importance of discussing diabetes with co-workers, but wants to settle in before beginning the conversation FORMCHECKBOX No, customer needs instruction on what to discuss with co-workers and how FORMCHECKBOX No, customer feels that diabetes is a personal matter and none of the co-worker’s businessComments and recommendations regarding Vocational Rehabilitation: FORMTEXT ?????Healthy Eating (VR and OIB) FORMTEXT ? Does the customer understand the effect of these foods on blood sugar? FORMTEXT ? FORMCHECKBOX Carbohydrates FORMCHECKBOX Proteins FORMCHECKBOX Fats FORMCHECKBOX None of these. Customer needs full education on the macronutrientsCan the customer verbalize appropriate portion sizes? FORMTEXT ? FORMCHECKBOX Carbohydrates FORMCHECKBOX Proteins FORMCHECKBOX Fats FORMCHECKBOX No. Customer needs training on portion sizingIs the customer able to verbalize healthy meal options? FORMTEXT ? FORMCHECKBOX Breakfast FORMCHECKBOX Lunch and Dinner FORMCHECKBOX Snacks FORMCHECKBOX No. Customer needs training on meal options.Does the customer understand the importance of timing of meals? FORMTEXT ? FORMCHECKBOX No, needs full education on timing of foods and medications FORMCHECKBOX Customer’s meals are well spaced but needs information about timing and medication FORMCHECKBOX Yes, customer follows meal and medication plan at least 80% of the timeWhat concerns does the customer have regarding healthy eating? FORMTEXT ? FORMCHECKBOX Food preferences FORMCHECKBOX Religious or cultural considerations FORMCHECKBOX Cost and availability of healthy foods FORMCHECKBOX No concernsDoes the customer need education on these eating habits? FORMTEXT ? FORMCHECKBOX Restaurants, Alcohol, and fast food FORMCHECKBOX Ability to prepare healthy foods FORMCHECKBOX Dietary restrictions related to health status (low fat, low salt, renal, etc.) FORMCHECKBOX None of these concernsComments or recommendations regarding healthy eating: FORMTEXT ?????Being Active (VR and OIB) FORMTEXT ?What physical problems limit the customer’s ability to exercise? FORMTEXT ? FORMCHECKBOX Hypoglycemia or Hyperglycemia FORMCHECKBOX Physical disability FORMCHECKBOX Motivation FORMCHECKBOX Customer should be able to participate in exercise.Does the customer have resources for exercise? FORMTEXT ? FORMCHECKBOX Treadmill, stationary bike, or other cardiovascular equipment FORMCHECKBOX Weights FORMCHECKBOX Workout videos or games FORMCHECKBOX NoneWhat activities has the customer enjoyed in the past? FORMTEXT ?????What activities would the customer like to do? FORMTEXT ?????What is the customer’s current exercise level? FORMTEXT ? FORMCHECKBOX None FORMCHECKBOX Seldom. Customer exercises less than one hour per week FORMCHECKBOX Occasionally. Customer exercises two to four hours per week FORMCHECKBOX Regular. Customer exercises five or more hours per weekComments or recommendations regarding being active? FORMTEXT ?????Monitoring (VR and OIB) FORMTEXT ?Does the customer have a blood glucose meter and testing supplies? FORMTEXT ? FORMCHECKBOX Yes, an audio meter and supplies FORMCHECKBOX Yes, a meter and supplies without audio features FORMCHECKBOX No, customer needs an audio meter and supplies FORMCHECKBOX No, customer wants a meter and supplies without audio featuresCurrent meter: FORMTEXT ?????Frequency of testing: FORMTEXT ?????Current blood glucose reading: FORMTEXT ? FORMCHECKBOX Premeal FORMCHECKBOX Post meal Date: FORMTEXT ????? Time: FORMTEXT ????? Result: FORMTEXT ?????Does the customer know his or her most recent A1c? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No Result: FORMTEXT ?????Does the customer: FORMTEXT ? FORMCHECKBOX Understand how to use the meter and get a drop of blood to the test strip FORMCHECKBOX Show willingness to monitor his or her blood sugar? FORMCHECKBOX Need education or motivation to monitor FORMCHECKBOX Monitoring is not recommended for this customerDoes the customer know how to respond to the results? FORMTEXT ? FORMCHECKBOX Yes, regarding adjustments in medications FORMCHECKBOX Yes, regarding adjustments in food FORMCHECKBOX Yes, regarding treatment of hypoglycemia and hyperglycemia and seeking medical help FORMCHECKBOX No, Customer does not know how to respond to the resultsIs the customer able to verbalize appropriate results? FORMTEXT ? FORMCHECKBOX Customer can verbalize individual blood sugar goals FORMCHECKBOX Customer can verbalize Hemoglobin A1c goals FORMCHECKBOX Customer can verbalize blood pressure goals FORMCHECKBOX Customer needs training on monitoring goalsDoes the customer monitor other health metrics? FORMTEXT ? FORMCHECKBOX Weight FORMCHECKBOX Ketones FORMCHECKBOX Blood pressure FORMCHECKBOX none of theseHow does the customer currently check his or her blood pressure? FORMTEXT ? FORMCHECKBOX Doctor’s office FORMCHECKBOX Pharmacy or grocery FORMCHECKBOX Home FORMCHECKBOX Does not checkWhat keeps the customer from monitoring? FORMTEXT ? FORMCHECKBOX Customer does not believe the results are useful FORMCHECKBOX Customer is unable to perform tasks independently FORMCHECKBOX Cost and availability of supplies FORMCHECKBOX Customer currently monitors appropriately.Is the customer able to: FORMTEXT ? FORMCHECKBOX Retrieve values from the meter’s memory and/or keep a record of results of blood sugars and other data FORMCHECKBOX Dispose of lancets and syringes appropriately FORMCHECKBOX Adjust his or her diet, medication, and activity based on results FORMCHECKBOX Customer uses results in day to day diabetes managementComments or recommendations regarding Monitoring? FORMTEXT ?????Taking Medication (VR and OIB) FORMTEXT ?List of current medications FORMTEXT ? FORMTEXT ?MedicationDosageFrequencyCondition1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????List any allergies (food or drug): FORMTEXT ?????How is insulin or injectable medication drawn and administered? FORMTEXT ? FORMCHECKBOX Independently without assistive devices FORMCHECKBOX Independently using assistive device (describe in comments) FORMCHECKBOX Support person assists in insulin administration FORMCHECKBOX Customer does not take insulin or other injectableDoes the customer verbalize information about insulin? FORMTEXT ? FORMCHECKBOX Customer verbalizes how to draw and administer, appropriate storage and travel FORMCHECKBOX Customer verbalizes appropriate injection sites and proper site rotation FORMCHECKBOX Customer verbalizes onset, peak, and duration FORMCHECKBOX Customer needs full training on insulinIs the customer able to manage other medications? FORMTEXT ? FORMCHECKBOX Customer has an organized method for storing and managing medications FORMCHECKBOX Customer needs instruction on storing and managing medication FORMCHECKBOX Customer uses vitamins and other alternative medicine (describe in comments) FORMCHECKBOX Customer is able to manage other medicationsThe customer: FORMTEXT ? FORMCHECKBOX Knows the purpose of his or her medications and how it works FORMCHECKBOX Takes medications as recommended FORMCHECKBOX Knows when to notify the doctor and knows what to ask when prescribed a new medication FORMCHECKBOX Customer needs training on medication(s).Comments and recommendation regarding taking medication: FORMTEXT ?????Healthy Coping (VR and OIB) FORMTEXT ?How does the customer feel about having diabetes? FORMTEXT ? FORMCHECKBOX Customer is in charge of the diabetes FORMCHECKBOX Customer doesn’t like it, but does the self-care tasks anyway FORMCHECKBOX Customer tries to manage it, but feels there is not much he or she can do FORMCHECKBOX Diabetes is in charge of customerDoes the customer have a support system? FORMTEXT ? FORMCHECKBOX Family and friends are physically and emotionally available to help customer FORMCHECKBOX Family and friends help customer in ways that the customer is resistant to receive FORMCHECKBOX There are family and friends available, but they have given up on helping customer FORMCHECKBOX Customer has no support systemDoes the customer have any issues regarding depression and diabetes? FORMTEXT ? FORMCHECKBOX Customer feels hopeful about the future and diabetes is manageable FORMCHECKBOX Customer has minor symptoms such as occasional blues, fearfulness, and sleeplessness FORMCHECKBOX Customer is okay right now but has been depressed in the past and is concerned about depression returning FORMCHECKBOX Customer is currently depressed and finds it difficult to deal with diabetes and other health issuesWhat does the customer do to manage stress? FORMTEXT ? FORMCHECKBOX Customer is not familiar with stress management techniques FORMCHECKBOX Customer uses prayer, deep breathing exercises, affirmations, etc. FORMCHECKBOX Customer has a strong support system FORMCHECKBOX Customer uses exercise and/or other active techniquesWhat help would the customer like regarding healthy coping? FORMTEXT ? FORMCHECKBOX Books, audio, website, and community resource recommendations FORMCHECKBOX Help with “diabetes police” and other caregiver concerns FORMCHECKBOX Help dealing with depression and diabetes issues FORMCHECKBOX Customer declines assistance with healthy copingComments and recommendations regarding healthy coping: FORMTEXT ?????Problem Solving (VR and OIB) FORMTEXT ? FORMTEXT ?What does the customer know about hypoglycemia? FORMTEXT ? FORMCHECKBOX Customer can verbalize the signs and symptoms and his or her personal response FORMCHECKBOX Customer can verbalize appropriate treatment FORMCHECKBOX Customer can verbalize a plan should hypoglycemia happen at work FORMCHECKBOX Customer needs training on hypoglycemiaWhat does the customer know about hyperglycemia? FORMTEXT ? FORMCHECKBOX Customer can verbalize the signs and symptoms and his or her personal response FORMCHECKBOX Customer can verbalize appropriate treatment FORMCHECKBOX Customer can verbalize a plan should hyperglycemia happen at work FORMCHECKBOX Customer needs training on hyperglycemiaWhat does the customer know about sick days? FORMTEXT ? FORMCHECKBOX Customer understands the importance of monitoring, taking medication, eating, and staying hydrated FORMCHECKBOX Customer has a sick day kit put together with cold medicines and other things needed to manage when he or she is sick FORMCHECKBOX Customer can verbalize when to call the doctor FORMCHECKBOX Customer needs education on managing sick daysThe customer is able to: FORMTEXT ? FORMCHECKBOX Perform a foot examination and verbalize appropriate skin and wound care FORMCHECKBOX Verbalize the importance of wearing medical identification FORMCHECKBOX Choose appropriate clothing, shoes and socks that are not binding FORMCHECKBOX Customer needs training on foot and skin ments and recommendations regarding problem solving: FORMTEXT ?????Reducing Risk (VR and OIB) FORMTEXT ? FORMTEXT ?Does the customer participate in risky behaviors? FORMTEXT ? FORMCHECKBOX Customer smokes FORMCHECKBOX Customer has problems with drugs or excessive alcohol usage FORMCHECKBOX Customer has participated in risky behaviors in the past and needs education about effect on health FORMCHECKBOX Customer does not smoke, drink excessively or have problems with drugsDoes the customer understand the consequences of diabetes mismanagement? FORMTEXT ? FORMCHECKBOX Cardiovascular risk including stroke FORMCHECKBOX Neuropathy and amputation risks FORMCHECKBOX Kidney disease risk FORMCHECKBOX Dental disease risk FORMCHECKBOX Customer needs training on risks of diabetes mismanagement. FORMTEXT ? Does the customer participate in regularly scheduled healthcare? FORMTEXT ? FORMCHECKBOX Regular doctor’s visits including a discussion of laboratory values for diabetes risk factors and immunizations FORMCHECKBOX Annual eye exams (minimum) FORMCHECKBOX Annual dental exams FORMCHECKBOX Foot exams by a professional FORMCHECKBOX Customer does not participate in scheduled healthcare (describe in comments)Comments and recommendations regarding reducing risk: FORMTEXT ?????Overall Recommendations FORMTEXT ?Recommended Diabetes Education Plan FORMTEXT ? FORMTEXT ?TopicNumber of MinutesKey Education NeededVocational Rehabilitation FORMTEXT ????? FORMTEXT ?????Healthy Eating FORMTEXT ????? FORMTEXT ?????Being Active FORMTEXT ????? FORMTEXT ?????Monitoring FORMTEXT ????? FORMTEXT ?????Taking Medication FORMTEXT ????? FORMTEXT ?????Healthy Coping FORMTEXT ????? FORMTEXT ?????Problem Solving FORMTEXT ????? FORMTEXT ?????Reducing Risk FORMTEXT ????? FORMTEXT ?????Total Minutes Recommended: FORMTEXT ?????Total Hours Recommended: FORMTEXT ?????Total number of hours is the anticipated time training will take. A one hour post training assessment should be conducted at least 30 days after the final training session. FORMTEXT ?The Diabetes Education Plan described above will address the following cultural influences: FORMTEXT ? FORMCHECKBOX Race FORMCHECKBOX Gender FORMCHECKBOX Ethnicity FORMCHECKBOX Culture FORMCHECKBOX Religion/Spirituality FORMCHECKBOX Socioeconomic Status FORMCHECKBOX ?Disability FORMCHECKBOX Person/family-centered beliefs FORMCHECKBOX Language FORMCHECKBOX Health Beliefs FORMCHECKBOX Work cultureEquipment Recommendations FORMTEXT ?Blood Glucose monitoring? FORMTEXT ? FORMCHECKBOX Prodigy Voice FORMCHECKBOX Prodigy Auto code (for Spanish, French, or Arabic speaking customers only) FORMCHECKBOX Other meter: Other meter Recommendation: FORMTEXT ?????Disability: FORMTEXT ?????Number of additional test strips to include (200 is standard): FORMTEXT ????? FORMCHECKBOX 200 LancetsInsulin Delivery FORMTEXT ? FORMCHECKBOX Count a Dose FORMCHECKBOX MagniguideOther Devices FORMTEXT ? FORMCHECKBOX Blood Pressure Monitor: FORMCHECKBOX Medium Cuff FORMCHECKBOX Large Cuff FORMCHECKBOX Talking FORMCHECKBOX Body weight scale FORMCHECKBOX Talking Body weight scale FORMCHECKBOX Diabetes Socks: Size: FORMTEXT ????? FORMCHECKBOX Medical ID FORMCHECKBOX Pill organizer FORMCHECKBOX Meal MeasureOther equipment or special needs (describe): FORMTEXT ?????Describe customer’s commitment to use equipment above (if provided): FORMTEXT ?????Disability Services FORMTEXT ? FORMTEXT ?Due to the customer’s disability, they have difficulty with the following which impacts their diabetes self-management: FORMTEXT ? FORMCHECKBOX Cooking skills: stovetop, microwave, oven, crock pot, George Foreman grill FORMCHECKBOX Adaptive kitchen tools, including timers FORMCHECKBOX Kitchen and meal organization, labeling, marking FORMCHECKBOX Following directions on recipes FORMCHECKBOX Grocery shopping, including identifying healthy foods and food freshness and purchasing diabetes management supplies FORMCHECKBOX Record keeping (glucose results log, medication list, important phone numbers) FORMCHECKBOX Medication labeling, marking, identifying, and organizational techniques and methods FORMCHECKBOX Setting reminders for medication or other health activities FORMCHECKBOX Being active without vision (O&M) FORMCHECKBOX Being active due to disability (Recreation)Additional comments regarding impact of disability and diabetes self-management: FORMTEXT ?????Customer’s Learning Style FORMTEXT ?Instructional method recommended: FORMTEXT ? FORMCHECKBOX Individualized training FORMCHECKBOX Group training FORMCHECKBOX CombinationLearning barriers: FORMTEXT ? FORMCHECKBOX Auditory FORMCHECKBOX Visual FORMCHECKBOX Literacy or numeracy FORMCHECKBOX Decreased hand sensation FORMCHECKBOX Cognition/Memory FORMCHECKBOX Other (specify): FORMTEXT ?????Highest level of education: FORMTEXT ?????Primary language: FORMTEXT ? FORMTEXT ? FORMCHECKBOX English FORMCHECKBOX Spanish FORMCHECKBOX Other (specify): FORMTEXT ?????Customer will work on this behavior change goal until our next visit (customer’s actions until next visit): FORMTEXT ?????Observations, comments, and recommendations not covered previously: FORMTEXT ?????Start time of visit: FORMTEXT ?????End time of visit: FORMTEXT ?????Date of assessment: FORMTEXT ?????Total hours for assessment: FORMTEXT ?????Provider Signatures FORMTEXT ?Diabetes Educator Signature (Required for all providers) FORMTEXT ?By signing below, I certify that: FORMTEXT ? the above dates, times, and services are accurate; FORMTEXT ?I personally facilitated all training, meeting all outcomes required for payment and documented the service, as prescribed in the VR-SFP and service authorization; FORMTEXT ? FORMTEXT ?Verification of the customer’s and/or customer’s authorized representative’s satisfaction and service delivery obtained as stated above; FORMTEXT ?I maintain the staff qualifications required for a Diabetes Educator as described in the VRSFP or Service Authorization; and FORMTEXT ?I signed my signature and entered the date below. FORMTEXT ?Typed or Printed name: FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Director (only required for Traditional-Bilateral Contractors) FORMTEXT ?By signing below, I, the Director, certify that: FORMTEXT ? I ensure that the services were provided by qualified staff, met all outcomes required for payment, and services were documented, as prescribed in the VR-SFP and service authorization; FORMTEXT ? FORMTEXT ?I maintain UNTWISE Director credential, as prescribed in VR-SFP; FORMTEXT ? I signed my signature and entered the date below. FORMTEXT ?Typed or Printed name: FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Select all that apply: FORMTEXT ? FORMCHECKBOX UNTWISE Credentialed with ID: FORMTEXT ????? FORMCHECKBOX VR3490-Waiver Proof AttachedVRS Use Only FORMTEXT ?If any question below is answered no or if the report or supporting documentation is missing or incomplete, return the invoice to the provider with the VR3460. Make a case note to document the results of the review and the date VR3460 was sent to provider, when applicable. FORMTEXT ? FORMTEXT ?Technical Review to Verify Provider Qualifications(Completed by any VR staff such as RA, CSC, VR Counselor) FORMTEXT ?Director’s Credential: FORMTEXT ?UNTWISE website or attached VR3490 verifies, for the dates of service, the director listed above: FORMTEXT ? FORMCHECKBOX maintained or waived the UNTWISE Director Credential FORMCHECKBOX did not hold a valid UNTWISE Director CredentialVerification of Service Delivery FORMTEXT ?Technical Review (completed by any VR staff such as RA, CSC, VR Counselor) FORMTEXT ?Verified that the report is accurately completed per form instructions FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the service(s) was provided within service date of SA and as stated in the VR Standards for Providers and/or the SA FORMCHECKBOX Yes FORMCHECKBOX NoWhen applicable, verify a copy of an approved VR3472 is attached to the report? FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoVerified that this individual session was held for two hours. FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the form was submitted to VRS within 35 days of completion. FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the appropriate fee(s) was invoiced FORMCHECKBOX Yes FORMCHECKBOX NoPrinted name of VR staff member making verification: FORMTEXT ?1. FORMTEXT ????? Date: FORMTEXT ?????2. FORMTEXT ????? Date: FORMTEXT ?????VR Counselor Review FORMTEXT ?Verified that the form reports the information the Diabetes Educator captured during the initial assessment as well as their recommendations for equipment and training. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoBy typing or printing your name, the VRC verifies: FORMTEXT ?completion of the technical review, FORMTEXT ?services provided met the customer’s individual needs, FORMTEXT ?services provided met specifications in the VR-SFP and on the SA, and FORMTEXT ?customer’s or legally authorized representative’s satisfaction with services received. FORMTEXT ? FORMCHECKBOX Approve to pay invoice FORMCHECKBOX Do not approve to pay invoiceVR Counselor: FORMTEXT ????? Date: FORMTEXT ????? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download