Contents
Form Example
Alamo Consumer Direct |
Consumer Directed Services |
Texas Department of Aging |
|
Phone: 512‐420‐0832, Toll Free: 1‐877‐903‐0832 |
Service Delivery Log with Written |
and Disability Services |
|
Toll Free Fax: 1‐877‐652‐0877 |
Narrative/Written Summary |
Form 1745‐compliant |
|
8701 Shoal Creek Blvd, Suite 303 |
|||
|
|
||
Austin TX 78757‐6809 |
|
|
Employee Name
Consumer Name
Time sheet due date: If faxed or dropped off, time sheets are due at the Consumer Direct office by Monday (at midnight) following the week of service. If mailed, they must be postmarked by Monday following the week of service. Late time sheets will result in late pay.
Check Program: 
DBMD 
CBA 
CLASS 
HCS 
PCS 
PHC 
TXHML
Sunday |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
Saturday |
Service Date
(mm/dd/yy)
Service Code
Time In
Time Out
Time In
Time Out
Time In
Time Out
Daily Total
NOTE: Time sheets must be signed AFTER the work is completed. Advance time sheets will not be accepted. Total Weekly Hours
Service Date
(mm/dd/yy)
Place of Service
Written Narrative/Summary
Employee/Consumer: I certify that the work hours listed above are accurate, and that services were provided in accordance with the Employee Work Schedule and Assigned Tasks (DADS 1731). I understand that falsification of this time sheet is considered Medicaid Fraud and may result in dismissal from the program and criminal prosecution.
Employee Signature |
Date |
Consumer Signature |
Date |
02052
REV. 06/27/2013
More PDF Templates
What Is a Order Form - A temporary order can provide immediate protection until the court hearing occurs.
Texas Form 05-169 - Complete Form 05-170 if a payment is being made based on this report.
Common mistakes
-
Incorrect Dates: Filling in the service dates incorrectly can lead to confusion and delays in processing. Ensure that the dates are accurate and in the correct format (mm/dd/yy).
-
Missing Signatures: Both the employee and consumer must sign the form after services are completed. Failing to include these signatures can result in the form being rejected.
-
Late Submission: Time sheets must be submitted by the specified deadlines. If they are faxed or dropped off, they are due by midnight on Monday following the service week. Mail submissions must be postmarked by the same Monday. Late submissions can lead to delayed payments.
-
Inaccurate Total Hours: Ensure that the total weekly hours accurately reflect the hours worked. Double-check calculations to avoid discrepancies.
-
Failure to Use Correct Service Codes: Each service date must include the appropriate service code. Using incorrect codes can lead to processing errors and payment delays.
-
Advance Time Sheets: Time sheets must be filled out after the work is completed. Submitting advance time sheets will not be accepted and can cause issues with payment.
-
Neglecting the Written Narrative: Providing a written narrative or summary is essential. This section must clearly describe the services provided to ensure compliance with program requirements.
Key takeaways
Here are key takeaways for filling out and using the Texas 1745 form:
- Understand the Purpose: The Texas 1745 form is used to document service delivery in consumer-directed services.
- Timely Submission: Time sheets must be submitted by Monday at midnight if faxed or dropped off. If mailed, they should be postmarked by the same deadline.
- Late Penalties: Late submission of time sheets can lead to delayed payment for services rendered.
- Service Codes: Ensure you check the appropriate program box (DBMD, CBA, CLASS, HCS, PCS, PHC, TXHML) to indicate the service type.
- Accurate Reporting: Fill in the service dates, codes, and hours worked accurately to avoid issues with payment and compliance.
- Signature Requirement: Both the employee and consumer must sign the time sheet after the work is completed. Advance signatures are not accepted.
- Falsification Consequences: Be aware that falsifying information on the time sheet can lead to serious consequences, including criminal charges.
- Weekly Total Hours: Calculate and report the total weekly hours worked clearly to ensure correct payment.
- Contact Information: For questions or assistance, contact the Texas Department of Aging at the provided phone numbers.
Steps to Using Texas 1745
After gathering the necessary information, you can proceed to fill out the Texas 1745 form. This form requires specific details about the services provided, including dates, times, and signatures. Accuracy is essential, as any discrepancies may lead to complications in processing.
- Begin by entering the Employee Name and Consumer Name at the top of the form.
- Fill in the time sheet due date. Remember, if you fax or drop off the form, it must be submitted by midnight on the Monday following the week of service. If mailing, ensure it is postmarked by the same Monday.
- Select the appropriate Check Program by marking the box next to one of the options: DBMD, CBA, CLASS, HCS, PCS, PHC, or TXHML.
- For each day of the week, enter the Service Date in the format mm/dd/yy.
- Record the Service Code for each service provided on the respective day.
- Document the Time In and Time Out for each service session. Ensure that you list these times accurately for each day of the week.
- Calculate the Daily Total hours worked for each day and enter it in the designated space.
- At the end of the week, total all the hours worked and enter the Total Weekly Hours in the provided field.
- Indicate the Place of Service where the services were rendered.
- Complete the Written Narrative/Summary section, certifying that the hours listed are accurate and that services were provided according to the Employee Work Schedule.
- Both the Employee Signature and Consumer Signature are required. Sign and date the form after all work is completed. Remember, advance time sheets will not be accepted.