John Hancock Independent Care Provider Service Reimbursement Instructions
This form contains 226 fields organized into 25 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Care Provider Information | ||
| Care Provider First Name | Text |
Enter the first name of the care provider.
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| Care Provider Middle Initial | Text |
Enter the middle initial of the care provider.
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| Care Provider Last Name | Text |
Enter the last name of the care provider.
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| Care Provider Phone Number | Text |
Enter the phone number of the care provider.
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| Care Provider Signature | ||
| Care Provider Signature | Date |
Please provide the signature of the care provider.
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| Contact Information | ||
| Insured First Name | Text |
Please provide the first name of the insured individual.
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| Insured Middle Initial | Text |
Please provide the middle initial of the insured individual.
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| Eighth Itemized Care Service | ||
| Eighth Service Date | Date |
Please enter the date when the eighth itemized care service was provided.
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| Eighth Service Time In | Time |
Please enter the time the eighth itemized care service began.
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| Eighth Service Time Out | Time |
Please enter the time the eighth itemized care service ended.
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| Eighth Service Total Hours | Number |
Please enter the total number of hours for the eighth itemized care service.
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| Eighth Service Hourly Charge | Number |
Please enter the hourly rate charged for the eighth itemized care service.
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| Eighth Service Total Daily Charge | Number |
Please enter the total charge for the eighth itemized care service for the day.
|
| Bathing | Checkbox |
Check this box if bathing assistance was provided for the eighth itemized care service.
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| Continence | Checkbox |
Check this box if continence care was provided for the eighth itemized care service.
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| Dressing | Checkbox |
Check this box if dressing assistance was provided for the eighth itemized care service.
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| Eating | Checkbox |
Check this box if eating assistance was provided for the eighth itemized care service.
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| Toileting | Checkbox |
Check this box if toileting assistance was provided for the eighth itemized care service.
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| Transferring/mobility | Checkbox |
Check this box if transferring or mobility assistance was provided for the eighth itemized care service.
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| Cognitive supervision | Checkbox |
Check this box if cognitive supervision was provided for the eighth itemized care service.
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| Other | Checkbox |
Check this box if other care services not listed were provided for the eighth itemized care service and specify details below.
|
| Eleventh Itemized Care Service | ||
| Date | Date |
Enter the date for this itemized care service.
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| Time In | Time |
Enter the start time for this itemized care service.
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| Time Out | Time |
Enter the end time for this itemized care service.
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| Total Hours | Number |
Enter the total number of hours for this itemized care service.
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| Hourly Charge | Number |
Enter the hourly charge for this itemized care service.
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| Total Daily Charge | Number |
Enter the total daily charge for this itemized care service.
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| Row 11 - Bathing | Checkbox |
Check this box if bathing assistance was provided on the date recorded in row 11.
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| Row 11 - Continence | Checkbox |
Check this box if continence care or assistance was provided on the date recorded in row 11.
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| Row 11 - Dressing | Checkbox |
Check this box if dressing assistance was provided on the date recorded in row 11.
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| Row 11 - Eating | Checkbox |
Check this box if feeding or eating assistance was provided on the date recorded in row 11.
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| Row 11 - Toileting | Checkbox |
Check this box if toileting assistance was provided on the date recorded in row 11.
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| Row 11 - Transferring/mobility | Checkbox |
Check this box if help with transferring or mobility was provided on the date recorded in row 11.
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| Row 11 - Cognitive supervision | Checkbox |
Check this box if cognitive supervision or monitoring was provided on the date recorded in row 11.
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| Row 11 - Other (detail below) | Checkbox |
Check this box if a different or additional care activity (to be detailed below) was provided on the date recorded in row 11.
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| Fifth Itemized Care Service | ||
| Fifth Service Date | Date |
Enter the date the fifth itemized care service was provided.
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| Fifth Service Time In | Time |
Enter the start time for the fifth itemized care service.
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| Fifth Service Time Out | Time |
Enter the end time for the fifth itemized care service.
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| Fifth Service Total Hours | Number |
Enter the total number of hours for the fifth itemized care service.
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| Fifth Service Hourly Charge | Number |
Enter the hourly charge for the fifth itemized care service.
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| Fifth Service Total Daily Charge | Number |
Enter the total daily charge for the fifth itemized care service.
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| Row 5 - Bathing | Checkbox |
Check this box if bathing assistance was provided during the care period recorded on row 5.
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| Row 5 - Continence | Checkbox |
Check this box if continence care (assistance with bladder or bowel management) was provided during the care period recorded on row 5.
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| Row 5 - Dressing | Checkbox |
Check this box if assistance with dressing was provided during the care period recorded on row 5.
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| Row 5 - Eating | Checkbox |
Check this box if feeding assistance or help with eating was provided during the care period recorded on row 5.
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| Row 5 - Toileting | Checkbox |
Check this box if assistance with toileting was provided during the care period recorded on row 5.
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| Row 5 - Transferring/mobility | Checkbox |
Check this box if assistance with transferring or mobility (for example, moving, standing, or walking) was provided during the care period recorded on row 5.
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| Row 5 - Cognitive supervision | Checkbox |
Check this box if cognitive supervision, cueing, or close safety monitoring was provided during the care period recorded on row 5.
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| Row 5 - Other (detail below) | Checkbox |
Check this box if an activity not listed above was provided during the care period recorded on row 5 and provide details in the 'Other' description area below.
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| First Itemized Care Service | ||
| Date | Date |
Enter the date the care service was provided.
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| Time In | Time |
Enter the start time of the care service.
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| Time Out | Time |
Enter the end time of the care service.
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| Total Hours | Number |
Enter the total number of hours the care service was provided.
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| Hourly Charge | Number |
Enter the hourly charge for the care service.
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| Total Daily Charge | Number |
Enter the total daily charge for the care service.
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| Bathing | Checkbox |
Check this box if the first itemized care service included assistance with bathing.
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| Continence | Checkbox |
Check this box if the first itemized care service included assistance with continence.
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| Dressing | Checkbox |
Check this box if the first itemized care service included assistance with dressing.
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| Eating | Checkbox |
Check this box if the first itemized care service included assistance with eating.
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| Toileting | Checkbox |
Check this box if the first itemized care service included assistance with toileting.
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| Transferring/mobility | Checkbox |
Check this box if the first itemized care service included assistance with transferring or mobility.
|
| Cognitive supervision | Checkbox |
Check this box if the first itemized care service included cognitive supervision.
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| Other (detail below) | Checkbox |
Check this box if the first itemized care service included other activities of daily living or supervision services not listed, and provide details elsewhere on the form.
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| Fourteenth Itemized Care Service | ||
| Fourteenth Care Service Date | Date |
Enter the date of the fourteenth itemized care service.
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| Fourteenth Care Service Time In | Time |
Enter the start time of the fourteenth itemized care service.
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| Fourteenth Care Service Time Out | Time |
Enter the end time of the fourteenth itemized care service.
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| Fourteenth Care Service Total Hours | Number |
Enter the total number of hours for the fourteenth itemized care service.
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| Fourteenth Care Service Hourly Charge | Number |
Enter the hourly charge for the fourteenth itemized care service.
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| Fourteenth Care Service Total Daily Charge | Number |
Enter the total daily charge for the fourteenth itemized care service.
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| Row 14 - Bathing | Checkbox |
Check this box if bathing assistance was provided for the service entry on row 14.
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| Row 14 - Continence | Checkbox |
Check this box if continence care (incontinence management) was provided for the service entry on row 14.
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| Row 14 - Dressing | Checkbox |
Check this box if dressing assistance was provided for the service entry on row 14.
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| Row 14 - Eating | Checkbox |
Check this box if eating/mealtime assistance was provided for the service entry on row 14.
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| Row 14 - Toileting | Checkbox |
Check this box if toileting assistance was provided for the service entry on row 14.
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| Row 14 - Transferring/mobility | Checkbox |
Check this box if transferring or mobility assistance was provided for the service entry on row 14.
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| Row 14 - Cognitive supervision | Checkbox |
Check this box if cognitive supervision or supervision for safety was provided for the service entry on row 14.
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| Row 14 - Other (detail below) | Checkbox |
Check this box if another type of activity not listed was provided for the service entry on row 14 and provide details in the 'If you selected other above, please provide detail' field.
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| Fourth Itemized Care Service | ||
| Row 4 - Date | Date |
Enter the date when the care service was provided for row 4.
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| Row 4 - Time in | Time |
Enter the start time when care began for the service on row 4.
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| Row 4 - Time out | Time |
Enter the end time when care concluded for the service on row 4.
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| Row 4 - Total hours | Number |
Enter the total number of hours worked for the service recorded on row 4.
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| Row 4 - Hourly charge | Number |
Enter the hourly charge amount billed for the service on row 4.
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| Row 4 - Total daily charge | Number |
Enter the total daily charge billed for all services on row 4.
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| Row 4 - Bathing | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver provided assistance with bathing.
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| Row 4 - Continence | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver provided assistance with continence (incontinence care or related toileting assistance).
|
| Row 4 - Dressing | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver assisted the person with dressing.
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| Row 4 - Eating | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver assisted the person with eating or feeding.
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| Row 4 - Toileting | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver assisted the person with toileting (including transfer to/from toilet and hygiene).
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| Row 4 - Transferring/mobility | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver assisted the person with transferring or mobility (e.g., moving between bed/chair, walking, use of mobility aids).
|
| Row 4 - Cognitive supervision | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver provided cognitive supervision or oversight to prevent harm (monitoring, cueing, or redirection).
|
| Row 4 - Other (detail below) | Checkbox |
Check this box if, on the date and times entered in row 4, the caregiver provided a service not listed above and you will describe the service in the 'Other' detail section below.
|
| General | ||
| Reset form | Button | |
| https://www.johnhancock.com/help-center/long-term-care/forms.html#numberOfResults=100 | Button | |
| johnhancock.com/ltc | Button | |
| Home Care Details | ||
| Yes | Checkbox |
Check this box if the care was provided at home.
|
| No | Checkbox |
Check this box if the care was not provided at home.
|
| Care Not At Home Details | Text |
Please provide details about where the care was provided if it was not at home. Fill only if 'No' is 'No'.
Depends on:
No
|
| Hospitalization/Facility Stay Information | ||
| Yes | Checkbox |
Check this box if the insured was hospitalized or in a facility this month.
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| No | Checkbox |
Check this box if the insured was not hospitalized or in a facility this month.
|
| Admission Date | Date |
Enter the date the insured was admitted to the hospital or facility. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Discharge Date | Date |
Enter the date the insured was discharged from the hospital or facility. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insured Person Information | ||
| Insured First Name | Text |
Please provide the first name of the insured person.
|
| Insured Middle Initial | Text |
Please provide the middle initial of the insured person.
|
| Insured Last Name | Text |
Please provide the last name of the insured person.
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| Insured Date of Birth | Date |
Please provide the date of birth for the insured person.
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| Insured/Fiduciary Signature and Title | ||
| Insured/Fiduciary Signature Date | Date |
Provide the date the insured or fiduciary signed this document.
|
| Power of Attorney | Checkbox |
Check this box if you are signing as a Power of Attorney for the insured/fiduciary.
|
| Guardian | Checkbox |
Check this box if you are signing as a Guardian for the insured/fiduciary.
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| Other | Checkbox |
Check this box if you are signing in a capacity other than Power of Attorney or Guardian for the insured/fiduciary.
|
| Other Title | Text |
If 'Other' was selected for the title, please specify the title of the insured or fiduciary. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Ninth Itemized Care Service | ||
| Ninth Care Service Date | Date |
Provide the date when the ninth itemized care service was provided.
|
| Ninth Care Service Time In | Time |
Enter the start time for the ninth itemized care service.
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| Ninth Care Service Time Out | Time |
Enter the end time for the ninth itemized care service.
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| Ninth Care Service Total Hours | Number |
Provide the total number of hours for the ninth itemized care service.
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| Ninth Care Service Hourly Charge | Number |
Enter the hourly charge for the ninth itemized care service.
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| Ninth Care Service Total Daily Charge | Number |
Enter the total daily charge for the ninth itemized care service.
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| Bathing | Checkbox |
Check this box if bathing assistance was provided as part of the Ninth Itemized Care Service.
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| Continence | Checkbox |
Check this box if continence care was provided as part of the Ninth Itemized Care Service.
|
| Dressing | Checkbox |
Check this box if dressing assistance was provided as part of the Ninth Itemized Care Service.
|
| Eating | Checkbox |
Check this box if eating assistance was provided as part of the Ninth Itemized Care Service.
|
| Toileting | Checkbox |
Check this box if toileting assistance was provided as part of the Ninth Itemized Care Service.
|
| Transferring/Mobility | Checkbox |
Check this box if transferring or mobility assistance was provided as part of the Ninth Itemized Care Service.
|
| Cognitive Supervision | Checkbox |
Check this box if cognitive supervision was provided as part of the Ninth Itemized Care Service.
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| Other | Checkbox |
Check this box if other daily living or supervision services, not listed, were provided as part of the Ninth Itemized Care Service and detail them below.
|
| Other Detail | ||
| Other Detail Description | Text |
Please provide a detailed description if you selected 'Other' for any of the activities of daily living/supervision services. Fill only if 'Other (detail below)', 'Other (detail below)', 'Other', 'Row 4 - Other (detail below)', 'Row 5 - Other (detail below)', 'Other (detail below)', 'Other', 'Other', 'Other', 'Row 10 - Other (detail below)', 'Row 11 - Other (detail below)', 'Other (detail below)', 'Other', 'Row 14 - Other (detail below)' is 'Yes' for any.
Depends on:
Other (detail below), Other (detail below), Other, Row 4 - Other (detail below), Row 5 - Other (detail below), Other (detail below), Other, Other, Other, Row 10 - Other (detail below), Row 11 - Other (detail below), Other (detail below), Other, Row 14 - Other (detail below)
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| Policy and Claim Numbers | ||
| Policy Number | Text |
Please enter the policy number associated with your insurance.
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| Claim Number | Text |
Please enter the claim number for this reimbursement request.
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| Second Itemized Care Service | ||
| Date | Date |
Please enter the date of the second itemized care service.
|
| Time In | Time |
Please enter the start time of the second itemized care service.
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| Time Out | Time |
Please enter the end time of the second itemized care service.
|
| Total Hours | Number |
Please enter the total number of hours for the second itemized care service.
|
| Hourly Charge | Number |
Please enter the hourly charge for the second itemized care service.
|
| Total Daily Charge | Number |
Please enter the total daily charge for the second itemized care service.
|
| Bathing | Checkbox |
Check this box if bathing assistance was provided as an activity of daily living/supervision service for the second itemized care service.
|
| Continence | Checkbox |
Check this box if continence assistance was provided as an activity of daily living/supervision service for the second itemized care service.
|
| Dressing | Checkbox |
Check this box if dressing assistance was provided as an activity of daily living/supervision service for the second itemized care service.
|
| Eating | Checkbox |
Check this box if eating assistance was provided as an activity of daily living/supervision service for the second itemized care service.
|
| Toileting | Checkbox |
Check this box if toileting assistance was provided as an activity of daily living/supervision service for the second itemized care service.
|
| Transferring/mobility | Checkbox |
Check this box if transferring or mobility assistance was provided as an activity of daily living/supervision service for the second itemized care service.
|
| Cognitive supervision | Checkbox |
Check this box if cognitive supervision was provided as an activity of daily living/supervision service for the second itemized care service.
|
| Other (detail below) | Checkbox |
Check this box if an activity of daily living or supervision service other than those listed was provided for the second itemized care service, and provide details in the section below.
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| Seventh Itemized Care Service | ||
| Date | Date |
Please provide the date of the care service.
|
| Time In | Time |
Please provide the start time of the care service.
|
| Time Out | Time |
Please provide the end time of the care service.
|
| Total Hours | Number |
Please provide the total number of hours for this care service.
|
| Hourly Charge | Number |
Please provide the hourly charge for this care service.
|
| Total Daily Charge | Number |
Please provide the total daily charge for this care service.
|
| Bathing | Checkbox |
Check this box if bathing assistance was provided for the seventh itemized care service.
|
| Continence | Checkbox |
Check this box if continence assistance was provided for the seventh itemized care service.
|
| Dressing | Checkbox |
Check this box if dressing assistance was provided for the seventh itemized care service.
|
| Eating | Checkbox |
Check this box if eating assistance was provided for the seventh itemized care service.
|
| Toileting | Checkbox |
Check this box if toileting assistance was provided for the seventh itemized care service.
|
| Transferring/Mobility | Checkbox |
Check this box if transferring or mobility assistance was provided for the seventh itemized care service.
|
| Cognitive Supervision | Checkbox |
Check this box if cognitive supervision was provided for the seventh itemized care service.
|
| Other | Checkbox |
Check this box if other unlisted daily living or supervision services were provided for the seventh itemized care service.
|
| Sixth Itemized Care Service | ||
| Date | Date |
Enter the date of the care service.
|
| Time In | Time |
Enter the start time of the care service.
|
| Time Out | Time |
Enter the end time of the care service.
|
| Total Hours | Number |
Enter the total number of hours for the care service.
|
| Hourly Charge | Number |
Enter the hourly charge for the care service.
|
| Total Daily Charge | Number |
Enter the total daily charge for the care service.
|
| Bathing | Checkbox |
Check this box if the sixth itemized care service included assistance with bathing.
|
| Continence | Checkbox |
Check this box if the sixth itemized care service included assistance with continence.
|
| Dressing | Checkbox |
Check this box if the sixth itemized care service included assistance with dressing.
|
| Eating | Checkbox |
Check this box if the sixth itemized care service included assistance with eating.
|
| Toileting | Checkbox |
Check this box if the sixth itemized care service included assistance with toileting.
|
| Transferring/Mobility | Checkbox |
Check this box if the sixth itemized care service included assistance with transferring or mobility.
|
| Cognitive Supervision | Checkbox |
Check this box if the sixth itemized care service included cognitive supervision.
|
| Other (detail below) | Checkbox |
Check this box if the sixth itemized care service included other activities not listed, and provide details in the designated area.
|
| Tenth Itemized Care Service | ||
| Tenth Itemized Care Service Date | Date |
Provide the date when the tenth itemized care service was provided.
|
| Tenth Itemized Care Service Time In | Time |
Enter the start time (time in) for the tenth itemized care service.
|
| Tenth Itemized Care Service Time Out | Time |
Enter the end time (time out) for the tenth itemized care service.
|
| Tenth Itemized Care Service Total Hours | Number |
Provide the total number of hours for the tenth itemized care service.
|
| Tenth Itemized Care Service Hourly Charge | Number |
Enter the hourly charge for the tenth itemized care service.
|
| Tenth Itemized Care Service Total Daily Charge | Number |
Provide the total daily charge for the tenth itemized care service.
|
| Row 10 - Bathing | Checkbox |
Check this box if the service on row 10 included assistance with bathing.
|
| Row 10 - Continence | Checkbox |
Check this box if the service on row 10 included assistance with bladder or bowel continence (incontinence care or related toileting assistance).
|
| Row 10 - Dressing | Checkbox |
Check this box if the service on row 10 included assistance with dressing.
|
| Row 10 - Eating | Checkbox |
Check this box if the service on row 10 included assistance with eating or feeding.
|
| Row 10 - Toileting | Checkbox |
Check this box if the service on row 10 included assistance with toileting (use of the toilet).
|
| Row 10 - Transferring/mobility | Checkbox |
Check this box if the service on row 10 included help with transferring or mobility (e.g., transfers, ambulation).
|
| Row 10 - Cognitive supervision | Checkbox |
Check this box if the service on row 10 included cognitive supervision or monitoring for safety.
|
| Row 10 - Other (detail below) | Checkbox |
Check this box if the service on row 10 included other activities not listed above and provide details in the 'Other' detail field below.
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| Third Itemized Care Service | ||
| Date of Service | Date |
Enter the date the care service was provided.
|
| Time In | Time |
Enter the time the care service began.
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| Time Out | Time |
Enter the time the care service ended.
|
| Total Hours | Number |
Enter the total number of hours for which care service was provided.
|
| Hourly Charge | Number |
Enter the hourly charge for the care service.
|
| Total Daily Charge | Number |
Enter the total charge for the care service on this day.
|
| Bathing | Checkbox |
Check this box if bathing assistance was provided as part of the third itemized care service.
|
| Continence | Checkbox |
Check this box if continence care was provided as part of the third itemized care service.
|
| Dressing | Checkbox |
Check this box if dressing assistance was provided as part of the third itemized care service.
|
| Eating | Checkbox |
Check this box if eating assistance was provided as part of the third itemized care service.
|
| Toileting | Checkbox |
Check this box if toileting assistance was provided as part of the third itemized care service.
|
| Transferring/mobility | Checkbox |
Check this box if transferring or mobility assistance was provided as part of the third itemized care service.
|
| Cognitive supervision | Checkbox |
Check this box if cognitive supervision was provided as part of the third itemized care service.
|
| Other | Checkbox |
Check this box if other, unlisted care services were provided as part of the third itemized care service.
|
| Thirteenth Itemized Care Service | ||
| Thirteenth Care Service Date | Date |
Enter the date of the thirteenth itemized care service.
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| Thirteenth Care Service Time In | Time |
Enter the start time of the thirteenth itemized care service.
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| Thirteenth Care Service Time Out | Time |
Enter the end time of the thirteenth itemized care service.
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| Thirteenth Care Service Total Hours | Number |
Enter the total number of hours for the thirteenth itemized care service.
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| Thirteenth Care Service Hourly Charge | Number |
Enter the hourly charge for the thirteenth itemized care service.
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| Thirteenth Care Service Total Daily Charge | Number |
Enter the total charge for the thirteenth itemized care service for the day.
|
| Bathing | Checkbox |
Check this box if bathing assistance was provided as part of the thirteenth itemized care service.
|
| Continence | Checkbox |
Check this box if continence care was provided as part of the thirteenth itemized care service.
|
| Dressing | Checkbox |
Check this box if dressing assistance was provided as part of the thirteenth itemized care service.
|
| Eating | Checkbox |
Check this box if eating assistance was provided as part of the thirteenth itemized care service.
|
| Toileting | Checkbox |
Check this box if toileting assistance was provided as part of the thirteenth itemized care service.
|
| Transferring/mobility | Checkbox |
Check this box if transferring or mobility assistance was provided as part of the thirteenth itemized care service.
|
| Cognitive supervision | Checkbox |
Check this box if cognitive supervision was provided as part of the thirteenth itemized care service.
|
| Other | Checkbox |
Check this box if other services not listed were provided as part of the thirteenth itemized care service, and provide details below.
|
| Total Charges | ||
| Total Charges | Number |
Provide the total amount of all charges.
|
| Twelfth Itemized Care Service | ||
| Twelfth Service Date | Date |
Enter the date the twelfth care service was provided.
|
| Twelfth Service Time In | Time |
Enter the time the twelfth care service began.
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| Twelfth Service Time Out | Time |
Enter the time the twelfth care service ended.
|
| Twelfth Service Total Hours | Number |
Enter the total number of hours for the twelfth care service.
|
| Twelfth Service Hourly Charge | Number |
Enter the hourly charge for the twelfth care service.
|
| Twelfth Service Total Daily Charge | Number |
Enter the total daily charge for the twelfth care service.
|
| Bathing | Checkbox |
Check this box if bathing was an activity of daily living or supervision service provided for the twelfth itemized care service.
|
| Continence | Checkbox |
Check this box if continence care was an activity of daily living or supervision service provided for the twelfth itemized care service.
|
| Dressing | Checkbox |
Check this box if dressing assistance was an activity of daily living or supervision service provided for the twelfth itemized care service.
|
| Eating | Checkbox |
Check this box if eating assistance was an activity of daily living or supervision service provided for the twelfth itemized care service.
|
| Toileting | Checkbox |
Check this box if toileting assistance was an activity of daily living or supervision service provided for the twelfth itemized care service.
|
| Transferring/mobility | Checkbox |
Check this box if transferring or mobility assistance was an activity of daily living or supervision service provided for the twelfth itemized care service.
|
| Cognitive supervision | Checkbox |
Check this box if cognitive supervision was an activity of daily living or supervision service provided for the twelfth itemized care service.
|
| Other (detail below) | Checkbox |
Check this box if an 'other' activity of daily living or supervision service (requiring detail below) was provided for the twelfth itemized care service.
|