Free 48203.pdf - Indiana

SOCIAL SERVICES BLOCK GRANT
State Form 48203 (2-97) / DHHS 0002

Mail to: Deaf and Hard of Hearing Services Family and Social Services Administration Division of Disability, Aging, and Rehabilitative Services P.O. Box 7083 Indianapolis, IN 46207-7083

Service authorization number

Name of vendor

Name of agency / firm / organization

Name of requestor

Telephone number

Address of requestor (number and street, city, state, ZIP code)

Name of consumer(s) Date requested

Situation

Service date

Date confirmed Actual service time

Requested service time

Total service time

A.M.

P.M. to

A.M.

P.M.

A.M.

P.M. to

A.M.

P.M.

Site of service address (number and street, city, state, ZIP code)

Travel from

Travel to

Total miles (round trip)

Type of service

Name of interpreter(s) or case worker

Interpreting
County of service

Case management

Signature of authorized vendor representative

Title

Date (month, day, year)

Administrative instructions or explanations

DISTRIBUTION: White - DHHS; Canary - Contractor