Describe the service activities provided by the CDAC provider. Enter the amount of time per day and the number of days per week or month required to provide the activity. Enter for components of the CDAC service that will not be “Not applicable” (NA) provided. *Reminders, cueing, and supervision are not billable CDAC services. List the amount Number of days Total Non-Skilled Service Components. of time required service will be minutes To be completed by the member Describe CDAC Provider Activity as allowable by each day for provided per for the or legal representative. the Iowa Administrative Code. each activity. month. line. member’s N1 Dressing 0 N2 Bathing, grooming, personal 0 hygiene includes shaving, hair – care, make-up, and oral hygiene. N3 Meal preparation and feeding 0 – includes cooking, eating, and feeding assistance (but not the cost of meals themselves). N4 Toileting includes bowel, bladder, 0 – and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter). N5 Transferring, ambulation, 0 mobility includes access to and – from bed or a wheelchair, repositioning, and mobility in general. N6 Essential housekeeping 0 – activities which are necessary for the health and welfare of the member such as grocery shopping, laundry, general cleaning. N7 Minor wound care includes foot 0 – care, skin care, nail trimming, and skin/nail observation and inspection. Member Name:
Describe the service activities provided by the CDAC provider. Enter the amount of time per day and the number of days per week or month required to provide the activity. Enter “Not applicable” (NA) for components of the CDAC service that will not be provided. *Reminders, cueing, and supervision are not billable CDAC services. Non-Skilled Service Components. To be completed by the member or member’s legal representative. Describe CDAC Provider Activity as allowable by the Iowa Administrative Code. List the amount of time required each day for each activity. Number of days service will be provided per month. Total minutes for the line. N1 Dressing 0 N2 Bathing, grooming, personal hygiene – includes shaving, hair care, make-up, and oral hygiene. 0 N3 Meal preparation and feeding – includes cooking, eating, and feeding assistance (but not the cost of meals themselves). 0 N4 Toileting – includes bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter). 0 N5 Transferring, ambulation, mobility – includes access to and from bed or a wheelchair, repositioning, and mobility in general. 0 N6 Essential housekeeping – activities which are necessary for the health and welfare of the member such as grocery shopping, laundry, general cleaning. 0 N7 Minor wound care – includes foot care, skin care, nail trimming, and skin/nail observation and inspection. 0 Member Name:
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