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Individual Provider Time Sheet - dshs wa

Individual Provider Time Sheet - dshs wa 2025

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The document is a time sheet for individual providers working under the Developmental Disabilities Administration (DDA) of Home and Community Services (HCS). It is used to record service hours, mileage, and tasks performed for clients with developmental disabilities. The form includes instructions for documenting authorized hours and emphasizes the importance of retaining completed sheets for six years. Signatures from both the client and provider are required.

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Click ‘Get Form’ to open the Individual Provider Time Sheet in the editor.
Begin by entering the CLIENT/EMPLOYER NAME at the top of the form. This identifies who you are providing services for.
For each day of the month, fill in the 'Time Service Began' and 'Time Service Ended' fields, ensuring to specify AM or PM.
Calculate and enter the 'Total Hours Each Day' based on your service times.
If applicable, document any mileage traveled for client-related tasks in the Mileage section.
Check off any tasks performed during the month as assigned in the client’s service plan, particularly if you are a personal care provider.
Finally, ensure both CLIENT’S SIGNATURE and INDIVIDUAL PROVIDER’S SIGNATURE are completed before saving your document.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (122 Votes)
2014	4 Satisfied (34 Votes)
2011	4.7 Satisfied (42 Votes)

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What is provider one in Washington state?

To be a paid caregiver you must Pass an in-state and federal (FBI) criminal conviction background check. Provide picture ID and be authorized to work in the U.S. Successfully complete all the caregiver training requirements (see below).

Does Washington have IHSS?

Stop Work Questionnaire (form 14-438) This form is used when you stop work or self employment. The form should be signed by you but must be completed by your employer. Your employer can also complete this form On-Line.

What is an individual provider?

Individual providers, or IPs, are people who provide in-home caregiving to another person, a client, who is eligible for Medicaid in-home care services. IPs must take training and get certified.

What is an individual provider in Washington state?

Verification Charts WHAT TO VERIFYACCEPTABLE VERIFICATION Identity (for Cash and Food) Drivers license State ID card Birth certificate Passport School records Current Alien Registration Card Collateral Contact outside the clients household SOLQ20 more rows