CMS Parents Intake Form

HOME HEALTH SERVICES COVERAGE AND LIMITATIONS HANDBOOK
PARENT OR LEGAL GUARDIAN STATEMENT OF WORK SCHEDULE
Recipients Name
ParentLegal Guardians Name
Statement of Work Schedule
Name of Employer
Address
Work Schedule
(Include work hours for each day)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
My signature below certifies that I am self-employed and that the schedule above is true and accurate. I understand that any person who makes, presents, or submits documentation that is false or fraudulent is subject to a reduction or termination of Medicaid services.
ParentLegal Guardian Signature

Clear
Date

MonthDayYear
Date
Recipients Name
Recipient Medicaid ID
AHCA-Med Serv Form 5000-3504, December 2011
Should be Empty:

PARENT OR LEGAL GUARDIAN STATEMENT OF WORK SCHEDULE