Caregiver Forms Feature

The Forms feature is available in the Caregiver Document Management page where caregiver-specific forms can be completed and managed.

Available Forms Closed

The following forms have been scanned, imported, and available to agencies:

Form Number / Name	State(s)	Description / Use
2067	Texas	Communication tool between provider and case manager; used to report updates, issues, changes in condition, or requests affecting the care plan.
3052	Texas	Practitioner’s Statement of Medical Need; certifies medical necessity for personal assistance services.
3054/3054-S	Texas	Service Delivery Record form, used by Caregivers to document services and hours worked for recipients of home and community support services. 3054-S is the Spanish version.
3599	Texas	Habilitation Service Provider Orientation/Supervisory Visits form, used when orienting a habilitation or PAS/HAB service provider by telephone or in person, or when providing an annual supervisory visit.
Attendant Orientation / Supervisory Visit Forms	Texas	Documentation of attendant/caregiver orientation, competency checks, and supervisory visits to ensure service quality.
M27	New York	Physician’s Order for Personal Care/Consumer Directed Personal Assistance Services (PCS/CDPAP); certifies medical necessity for homecare based on medical assessment.
M27R	New York	Physician’s Reassessment for Personal Care/Consumer Directed Personal Assistance Services; used for periodic recertification of medical necessity and updates to the care plan.
M27T	New York	Authorization to Release Medical/Treatment Information, allows HRA to obtain medical records from healthcare providers to determine eligibility for benefits or services.
PAS Individual Evaluation / Service Plan	Texas	Evaluates functional needs and establishes the service plan for Personal Assistance Services programs.
PERS Documentation (Personal Emergency Response Service)	Nationwide	Documents eligibility, installation, monitoring, and continued use of emergency alert devices for at-risk individuals.
PHC Individual Evaluation / Service Plan	Texas	Functional assessment and service plan for the Primary Home Care program, determining authorized PAS services.

Form Field Mapping: Auto-Filled Fields Closed

The table below provides the field mapping across all forms. The first column is the form field, the second column is a field description, and the third column is the path where the information comes from in the system to pre-fill the forms.

Field	Field Description	Path/Navigation
Individual Name	Patient's name in their profile	Patient > Profile > Name
Individual Number	Patient’s Medicaid ID	Patient > Profile > Admission ID
Individual Address	Patient's primary address	Patient > Address (primary)
Attendant A, B, C	Name and code of caregivers in patient's history	Patient > Caregiver History > Caregiver Name + caregiver code
Tasks	Most recently created plan of care for the patient	Patient > Plan of Care (most recently created plan)
Agency Name	Name of the agency in its profile	Agency Profile > Agency Name
Vendor No.	Provider contract number in authorization settings	Authorizations > Edit Authorization > Provider Contract Number
Attendant Schedule (A, B, C)	Visits scheduled corresponding to selected caregivers	Patient > Masterweek (visits corresponding with the caregivers selected above)
Total HRS	Sum of daily or weekly totals	Sum daily/weekly totals
From > Agency Name	Name of the agency in its administrative profile in response	Admin > Agency Profile > Agency Name in response
From > Agency Address	Address of the agency in its office setup in response	Admin > Office Setup > Address in response
From > Phone	Phone number of the agency in its office setup in response	Admin > Office Setup > Phone in response
From > Fax	Fax number of the agency in its office setup in response	Admin > Office Setup > Fax in response
Case Name	Name of the patient in their profile	Patient > Patient Name
Case No.	Alternate patient ID based on selected contract	Patient > Contracts > Alt Patient ID
Category 2	Additional contract category in patient's profile	Patient > Contract
Address (Street, City, State, Zip Code)	Default address of the patient	Patient > Address (Default to primary)
Area Code and Telephone No.	Phone number of the agency in its office setup in response	Admin > Office Setup > Phone in response
Supervisor	Name and code of caregivers in patient's history	Patient > Caregiver History > Caregiver Name + caregiver code
Contract No.	Provider contract number in authorization settings	Authorizations > Edit Authorization > Provider Contract Number
Employee Name/No	Name and code of caregivers in patient's history	Patient > Caregiver History > Caregiver Name + caregiver code
County	County in the patient's address (defaulting to current address)	Patient > Profile > Address > County
Task(s) Assigned	Most recently created plan of care for the patient	Patient > Plan of Care (Use most recently created plan)
Scheduled or Authorized Hours > In	Start time in the master week for the patient including daily variable hours	Patient > Master Week
Scheduled or Authorized Hours > Out	End time in the master week for the patient including daily variable hours	Patient > Master Week
Scheduled or Authorized Hours > Total	Total hours scheduled in all overlapping master weeks	Patient > Master Week
Total Authorized Hours Per Week	Sum of the total hours above	Sum of the above totals
Record of Time > In	Visit EVV start time in the patient's calendar	Patient Calendar > Visit Start Time
Record of Time > Out	Visit EVV end time in the patient's calendar	Patient Calendar > Visit End Time
Record of Time > Total Daily Time	Total daily time recorded in the patient's calendar	Visit Start Time minute Visit End Time above
Monthly Total of Hours	Sum of the above totals	Sum of the above totals
Habilitation Provider Schedules > Schedule 1 > Type of Service	Schedule in the master week based on service code	Patient > Masterweek
Habilitation Provider Schedules > Schedule 1 > Schedule	Schedule in the master week based on service code	Patient > Masterweek
Habilitation Provider Schedules > Schedule 1 > Weekly hours	Schedule in the master week based on service code	Patient > Masterweek
Habilitation Provider Schedules > Schedule 2 > Type of Service	Schedule in the master week based on service code	Patient > Masterweek
Habilitation Provider Schedules > Schedule 2 > Schedule	Schedule in the master week based on service code	Patient > Masterweek
Habilitation Provider Schedules > Schedule 2 > Weekly hours	Schedule in the master week based on service code	Patient > Masterweek
Response > To > Agency Name	Name of the agency in its administrative profile	Admin > Agency Profile > Agency Name
Response > To > Agency Address	Address of the agency in its office setup	Admin > Office Setup > Address
Response > To > Phone	Phone number of the agency in its office setup	Admin > Office Setup > Phone
Response > To > Fax	Fax number of the agency in its office setup	Admin > Office Setup > Fax
Caregiver Name	Name of the Caregiver if Caregiver Profile matches username	Caregiver Profile
Patient Gender	Gender of Patient	Patient Profile > Profile
Patient SSN	Patient Social Security Number	Patient Profile > Profile
Patient DOB	Patient Date of Birth	Patient Profile > Profile
Patient Start of Care Date	Start of care date for Patient	Patient Profile > General > Service Request Start Date
Patient Emergency Contact Details	Emergency contact name, relationship, primary phone	Patient Profile > Profile > Emergency Contact
Medication Profile	Patient Medications	Patient Profile > Med Profile
Diagnosis	Patient Diagnosis Codes	Patient Profile > Clinical Info > Diagnosis

Other Resources

Enable the Forms Feature

Patient Forms Feature