DR 296A - California Department of Rehabilitation - rehab cahwnet: Fill out & sign online

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Click ‘Get Form’ to open the DR 296A in the editor.
Begin by entering the 'Service Month/Year' in the designated field, indicating when you provided services.
Fill in your 'Provider Name' and the 'Consumer Name' as per the details on the DR 297B form.
Input the 'Counselor Name' who referred you to the consumer, also found on the DR 297B form.
Specify the 'Authorized Dates of Service', which should reflect your approved service timeframe from the DR 297B.
Record each date you provided services, along with corresponding times and hours worked using quarter increments.
Describe the services rendered in detail, ensuring clarity for reimbursement purposes.
If applicable, enter transportation costs including total miles and any other expenses like tolls or parking.
Finally, sign your name in blue or black ink before saving and submitting your completed form.

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