FPCS 2026

Family Person-Centered Support 1:1

WEST VIRGINIA I/DD WAIVER DIRECT SUPPORT SERVICE LOG
Client Name A
Waiver Client First Name
Client First Name
Waiver Client Last Name
Client Last Name, Including Jr, II, etc.
CONFIRM WAIVER CLIENT FIRST NAME
Confirm Client First Name
CONFIRM WAIVER CLIENT LAST NAME
Confirm Client Last Name, Including Jr, II, etc.
Please use Jr, II, etc.
NAMES DO NOT MATCH
Billing For Services For The Week Of:
PLEASE SELECT HOW MANY TIME ENTRIES YOU NEED
Month/Year of Service
SATURDAY
Saturday - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Saturday - Time #1

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Saturday - Time #2

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Saturday - Time #3

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Saturday #1 - Training Provided?
Saturday #2 - Training Provided?
Saturday #3 - Training Provided?
Saturday #1 - Provider Initials
Saturday #2 - Provider Initials
Saturday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR SATURDAY
SUNDAY
Sunday - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sunday - Time #1

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Sunday - Time #2

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Sunday - Time #3

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Sunday #1 - Training Provided?
Sunday #2 - Training Provided?
Sunday #3 - Training Provided?
Sunday #1 - Provider Initials
Sunday #2 - Provider Initials
Sunday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR SUNDAY
MONDAY
Monday - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Monday - Time #1

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Monday - Time #2

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Monday - Time #3

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Monday #1 - Training Provided?
Monday #2 - Training Provided?
Monday #3 - Training Provided?
Monday #1 - Provider Initials
Monday #2 - Provider Initials
Monday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR MONDAY
TUESDAY
Tuesday - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Tuesday - Time #1

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Tuesday - Time #2

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Tuesday - Time #3

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Tuesday #1 - Training Provided?
Tuesday #2 - Training Provided?
Tuesday #3 - Training Provided?
Tuesday #1 - Provider Initials
Tuesday #2 - Provider Initials
Tuesday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR TUESDAY
WEDNESDAY
Wednesday - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Wednesday - Time #1

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Wednesday - Time #2

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Wednesday - Time #3

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Wednesday #1 - Training Provided?
Wednesday #2 - Training Provided?
Wednesday #3 - Training Provided?
Wednesday #1 - Provider Initials
Wednesday #2 - Provider Initials
Wednesday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR WEDNESDAY
THURSDAY
Thursday - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Thursday - Time #1

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Thursday - Time #2

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Thursday - Time #3

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Thursday #1 - Training Provided?
Thursday #1 - Provider Initials
Thursday #2 - Training Provided?
Thursday #2 - Provider Initials
Thursday #3 - Training Provided?
Thursday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR THURSDAY
FRIDAY
Friday - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Friday- Time #1

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Friday - Time #2

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Friday - Time #3

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Friday #1 - Training Provided?
Friday #1 - Provider Initials
Friday #2 - Training Provided?
Friday #2 - Provider Initials
Friday #3 - Training Provided?
Friday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR FRIDAY
THIS IS THE TOTAL NUMBER OF HOURS YOU HAVE ENTERED ON THIS FORM
Total Units
REMINDER:

If you bill for mileage,

your mileage for December 2025 is due.
REMINDER:

If you bill for mileage,

your mileage for January 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for February 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for March 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for April 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for May 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for June 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for July 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for August 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for September 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for October 2026 is due.
REMINDER:

If you bill for mileage,

your mileage for November 2026 is due.
The Person Who Is Billing First Name
The Person Who Is Billing Last Name
THE PERSON BILLING NAME CANNOT BE THE SAME AS THE WAIVER CLIENT NAME
Provider Name 2
First Initial
Last Initial
Provider Initials
ID
ID Sat
ID Sun
ID Mon
ID Tues
ID Wed
ID Thur
ID Fri
Provider E-Mail
Provider Cell Phone Number
This is to ensure we have your current contact number. Format: (000) 000-0000.
Do You Complete Task Analysis For A Behavior Support Professional?
Provider Name 2 NEW
Person Billing Signature
Unique Field
Should be Empty:

Family Person-Centered Support 1:1

SATURDAY

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY