Form 3625-2026

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4.6 out of 5

51 votes

The document is a form from the Texas Department of Aging and Disability Services, specifically Form 3625, used for documenting services delivered under the Community Living Assistance and Support Services program. It includes sections for participant information, provider agency details, assessments, case management services, direct service delivery methods, a record of time worked, and certification signatures from service providers and participants.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Service Month and Year' at the top of the form. This sets the context for the services delivered.
In Section A, fill out the 'Participant Information' including their name, Medicaid number, and Social Security number if applicable.
Proceed to Section B to provide 'Provider Agency Information.' Specify the agency type, name, and vendor number.
In Section C, indicate any pre-enrollment assessment fees by checking either 'Full Assessment' or 'Partial Assessment' for case management services.
Section D requires you to enter the case manager's name and specify ongoing case management services provided.
For Section E, select a method of delivery and provide details about authorized services including service category and codes.
Document time records in Section F by entering day, time in/out, units, and amount for each service rendered.
Finally, complete Section G by obtaining necessary signatures from all parties involved along with dates.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (203 Votes)
2010	4 Satisfied (51 Votes)
2003	4.6 Satisfied (51 Votes)

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Form 3625-2026

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