Completed Form 3625, CLASS/CFC – Documentation of Services Delivered. Partial Assessment — Check this box for reimbursement for a partial assessment provided during the initial assessment process.

The purpose of this section is to make the most current forms available with a single resource. Forms are used to collect information and remain in the handbook until the form is no longer necessary. ES = Spanish version available.

Form 3625, CLASS/CFC Documentation of Services Delivered Author: Texas Health and Handbook Services Subject: Form 3625, CLASS/CFC Documentation of Services Delivered Created Date: 10/24/2024 8:48:14 AM

2023年7月24日 · Community Living Assistance and Support Services (CLASS) program Form 3625, CLASS/CFC Documentation of Services Delivered, has been updated and now available online. The Spanish version of Form 3625 is not currently available but will be published online in the coming weeks.

Form 3625 February 2003 1. Service Month and Year Section A – Participant Information 2. Participant Name 3. Medicaid No. 4. Social Security No. (for applicants only) Section B – Provider Agency Information 5. Agency Type 6. Agency Name 7. Vendor No. CMA DSA Section C – Pre-Enrollment Assessment Fees: CMA/DSA 8. Case Management Services 9.

form . 3625 back (10-91) instructions. special notice 1: the confined space entry permit is not a permit to conduct "hot work" operations that are covered under the provisions of the osha standard 29 cfr 1910, subpart q-welding, cutting and brazing. for "hot work" operations, a separate permit (gsa form 1755) is required. if "hot work"

How to fill out and sign Form 3625 online? Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below: Legal, tax, business and other electronic documents demand an advanced level of protection and compliance with the law.

Form 3625, CLASS/CFC - Documentation of Services Delivered To serve as the primary source billing document for services provided by non-employees of the CLASS direct service agency through personal service agreement, ...

2024年8月29日 · Changes to Form 3625 CLASS/CFC - Documentation of Services Delivered and Form 6505, DBMD/CFC - Summary of Services Delivered, and Services Documented through Electronic Visit Verification (EVV) System