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Dhs 4691

Refusal medical 2026

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The document is a PCA (Personal Care Assistant) Time and Activity Documentation form used to record the services provided by a PCA to a recipient. It includes sections for documenting dates of service, activities performed, time in and out for visits, staff-to-recipient ratios, and required signatures for verification. The form emphasizes the importance of accurate reporting to prevent fraud and outlines specific activities related to personal care.

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Click ‘Get Form’ to open the refusal medical document in the editor.
Begin by entering the PCA agency name and phone number at the top of the form. This information is essential for identification.
Fill in the dates of service in consecutive order, using the MM/DD/YY format. Ensure that any dates where services were not provided are crossed out by the recipient.
In the Activities section, initial next to each activity you provided care for on that date. Remember, only initial once per day for repeated activities.
Document visit details including time in and time out, circling AM or PM as appropriate. Make sure to accurately reflect your service times.
Complete the Acknowledgement and Required Signatures section by having both the recipient and PCA sign and date the form, confirming accuracy.

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