This form must be used to summarize Community Living Assistance and Support Services (CLASS) services provided by the CLASS Case Management Agency (CMA) or Direct Services Agency (DSA) to a person in a calendar month. Exceptions: Adaptive aids, dental treatment and minor home modifications do not need to be summarized on this form.

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 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"

Are you forced to change and fill out Form 3625? With a robust editor like ours, you can complete this in mere minutes without the need to print and scan papers back and forth. We provide you with fully editable and simple form templates that will serve as a start and help you fill out the necessary document template online.

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.

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