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.

Check out our various publications and manuals to learn more about what the Postal Service can do for you. Access the most often used business mailer forms here. Here you’ll find all the forms necessary to handle your business mailing needs. A convenient and fast way to order large quantities of stamps for your business. Learn more. PDF | TXT.

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.

For your convenience, Design & Construction has made forms available for printing or downloading and filling out. Please be sure to use forms from this location as forms are often updated. Please expand one of the categories below and choose the appropriate form.

Complete TX HHS 3625 2015-2025 online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. Save or instantly send your ready documents.

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, ...