DADS or HHSC Form

							Texas Department of Aging                         Deaf Blind with Multiple Disabilities (DBMD)                                                   Form 6503
and Disability Services                                                                                                                           July 2010
                                                   Summary of Services Delivered

Month:                  Year:                                             Program Provider Name                              Program Provider No.


Individual’s Name                                                                            Medicaid No.                    Birth Date


Service Provider Name                                      Contract with other Agency        Name of Company (if contract with other agency)
                                                              Yes         No
Authorized Service (check only one)
       7-Occupational Therapy           12-Case Management                                17E-Chore                         44-Orientation and Mobility
       8-Physical Therapy               13A-Licensed Vocational Nursing (LVN)             34-Dietary Services               45-Intervener
       9-Speech Therapy                 13B-Registered Nursing (RN)                       35-Audiology                      45A-Intervener I
       10-Day Habilitation              13C-Specialized Nursing (RN)                      37-Supported Employment           45B-Intervener II
       11-Respite (In-Home)             13D-Specialized Nursing (LVN)                     40-Pre Assessment                 45C-Intervener III
       11A-Respite (Out-of-Home)        17-Residential Habilitation (Hourly)              43A-Behavioral Support            54-Employment Assistance

Hours Worked (to be completed by employee)
Date      Time In     Time Out     Time In   Time Out       Time In      Time Out   Total Time      Comments
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 31
                                                         Pay Period Total Hours


          Service Provider Name                            Signature – Service Provider                              Date



             Timekeeper Name                                 Signature – Timekeeper                                  Date