CONTACTS & SUMMARY OF START END SAM SUMMARY OF STEPS TAKEN STAFF DATE UNITS TIME TIME Level ISSUE(S)/CONCERN(S) TO RESOLVE INITIALS ISSUE(S)/CONCERN(S) 0 0 FIELD ENTRY TYPE INFORMATION Enter the date that the service took place. Date will DATE FIELD DATE also auto-populate the Job Task Section. MM/DD/YY (REQUIRED FIELD) Enter the time that the actual service started, not the TIME FIELD START TIME scheduled start time. AM/PM (REQUIRED FIELD) Enter the time that the actual service ended, not the TIME FIELD END TIME scheduled end time. AM/PM (REQUIRED FIELD) Field is calculated based on information entered in the UNITS NON-EDITABLE report form. Providers may not edit this field. Enter the SAM Level if VR Counselor or VR Contractor SAM LEVEL DROP DOWN has authorized SAM Level for the service. SUMMARY OF ISSUE(S)/CONCERN(S) Enter a summary of the issue that was worked on that TEXT specific date. CONTACTS & SUMMARY OF STEPS Enter documentation of the type of contact or what TAKEN TO RESOLVE TEXT actions were taken to resolve the issue on that specific ISSUE(S)/CONCERN(S) date. STAFF INTIALS TEXT Enter the initials of the Provider Staff who provided direct service to the Individual on the date. INTERPRETING SPECIAL INSTRUCTIONS Due to the nature of the service, e.g. taking place in the community at different locations and needing the form to be signed, Interpreters can print off copies and hand write entries. Participants may have forms from various Interpreters if multiple staff were used to serve the individual throughout the month. Interpreters should bill all service at the end of the month or at the end of the billing cycle as defined on the Original VR Authorization & Billing (OOD-0020). INVOICE SECTION SERVICE DESCRIPTION (UOS) TOTAL $0.00 SERVICE AREA MODIFIER TOTAL $0.00
DATE START TIME END TIME UNITS SAM Level SUMMARY OF ISSUE(S)/CONCERN(S) CONTACTS & SUMMARY OF STEPS TAKEN TO RESOLVE ISSUE(S)/CONCERN(S) STAFF INITIALS 0 0 FIELD ENTRY TYPE INFORMATION DATE DATE FIELD MM/DD/YY Enter the date that the service took place. Date will also auto-populate the Job Task Section. (REQUIRED FIELD) START TIME TIME FIELD AM/PM Enter the time that the actual service started, not the scheduled start time. (REQUIRED FIELD) END TIME TIME FIELD AM/PM Enter the time that the actual service ended, not the scheduled end time. (REQUIRED FIELD) UNITS NON-EDITABLE Field is calculated based on information entered in the report form. Providers may not edit this field. SAM LEVEL DROP DOWN Enter the SAM Level if VR Counselor or VR Contractor has authorized SAM Level for the service. SUMMARY OF ISSUE(S)/CONCERN(S) TEXT Enter a summary of the issue that was worked on that specific date. CONTACTS & SUMMARY OF STEPS TAKEN TO RESOLVE ISSUE(S)/CONCERN(S) TEXT Enter documentation of the type of contact or what actions were taken to resolve the issue on that specific date. STAFF INTIALS TEXT Enter the initials of the Provider Staff who provided direct service to the Individual on the date. INTERPRETING SPECIAL INSTRUCTIONS Due to the nature of the service, e.g. taking place in the community at different locations and needing the form to be signed, Interpreters can print off copies and hand write entries. Participants may have forms from various Interpreters if multiple staff were used to serve the individual throughout the month. Interpreters should bill all service at the end of the month or at the end of the billing cycle as defined on the Original VR Authorization & Billing (OOD-0020). INVOICE SECTION SERVICE DESCRIPTION (UOS) TOTAL $0.00 SERVICE AREA MODIFIER TOTAL $0.00
VR%20Forms%20Instructions%20Examples.docx