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EXPRS Plan of Care - Services Delivered Report Form - apps state or 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Customer Name, Prime, Provider Name, and Provider Number in the designated fields at the top of the form.
- Fill in the CM Organization and SC/PA Name to ensure proper identification of service providers.
- In the 'Service Authorized' section, specify the type of service, modification code, units, and frequency as required.
- Document each service delivered by entering the date, start time, end time, and total units/hours for each entry. Ensure accuracy for compliance.
- Complete the SERVICE GOAL and PROGRESS NOTES sections to provide context on service delivery. Attach additional pages if necessary.
- Both customer/employer and provider/employee must sign and date their respective verification sections to confirm accuracy.
- Finally, submit this completed form to the appropriate CDDP/Brokerage or CIIS Program for processing.
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