DDAP-EFM-1006 12/15 Services Rendered Provider Location: Provider Name: (i.e., Encounters) (Required fields are in BOLD) DDAP License #: UCN: Date: First Name: M.I.: Last Name: Suffix: Service Rendered Authorization #: Final: Yes No #: Billed: Clinician: Client Diagnosis: Service Service Start Service Service End Start Date: Time: End Date: Time: Authorized Services Rendered Units UOM Comments: Form to be submitted to SCA if required by the SCA.
DDAP-EFM-1006 12/15 Services Rendered (i.e., Encounters) (Required fields are in BOLD) Provider Location: Provider Name: DDAP License #: UCN: Date: First Name: M.I.: Last Name: Suffix: Service Rendered Authorization #: #: Final: Billed: Yes No Clinician: Client Diagnosis: Service Start Date: Service Start Time: Service End Date: Service End Time: Authorized Services Rendered Units UOM Comments: Form to be submitted to SCA if required by the SCA.