EXPRS Plan of Care - Services Delivered Report Form - apps state or 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the Customer Name, Prime, Provider Name, and Provider Number in the designated fields at the top of the form.
  3. Fill in the CM Organization and SC/PA Name to ensure proper identification of service providers.
  4. In the 'Service Authorized' section, specify the type of service, modification code, units, and frequency as required.
  5. Document each service delivered by entering the date, start time, end time, and total units/hours for each entry. Ensure accuracy for compliance.
  6. Complete the SERVICE GOAL and PROGRESS NOTES sections to provide context on service delivery. Attach additional pages if necessary.
  7. Both customer/employer and provider/employee must sign and date their respective verification sections to confirm accuracy.
  8. Finally, submit this completed form to the appropriate CDDP/Brokerage or CIIS Program for processing.

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