Free Form 02AS004E (AS-ADS-1) Instructions - Oklahoma

Service Attendance/Claim Record Purpose of Form

02AS004E (AS-ADS-1)

Form 02AS004E is used by the Oklahoma Department of Human Services (OKDHS) approved facilities to record information needed to file a claim for each OKDHS client in adult day services. It is required by OKDHS for providers submitting claims for adult day services and provides a convenient way of keeping records of attendance for each person, type and number of units, rate per unit, and the amount claimed for each person during the month. Instructions for Preparation of Form An original of the form is prepared for each client for whom the provider is authorized to claim reimbursement from OKDHS. It is kept current during the month. For the month of. Enter the month and year during which services were provided. Facility name. Enter the name of the facility providing care as it is shown on the approved contract. This must be the same name as shown on the claimant line on Form 02AS001E, Adult Day Service Invoice. County. Enter the county that has authorized OKDHS participation. Case number. If reimbursement from OKDHS is claimed, enter the service case number. Services received during days in attendance. For each day or part of a day the person is in attendance, indicate the service(s) received. Indicate where appropriate if services are individualized (I) or group (G) activities. Hours per day. Complete this block only when an H is shown in the charge code block. This block is the agency's method for the conversion from charges to authorized payments. Enter the number of hourly units each day that are being claimed at the hourly charge. This block is completed in quarter hours, half hours, and hours only. In all instances, the hourly rate charged can never exceed the authorized daily rate of pay or the OKDHS maximum daily rate. Charge code. For each day or part of the day the person is in attendance, enter the appropriate D for daily, or H for hourly. The person may have different charge codes for days in attendance during the month. Hourly charge amount. Enter a money amount for the hourly rate. Units. Enter the total of the number of daily and hourly units from the daily attendance record. Amount. Enter a money amount for the daily or hourly rate. Routing of Form The original(s) are batched in alphabetical order by the last name of the service recipient. Original and one copy of Form 02AS001E, and the original(s) of Form 02AS004E are sent to Aging Services Division. One copy of the form is retained by the facility. One copy of the form is given to the client, caretaker, family member, or guardian.

OKDHS revised 7-1-2005

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