Arizona Quarterly Report 1404A Reference Information

ItemWhere the information is found or where it is entered
Qualified Vendor NameAgency Name on Agency record marked as Customer
Contact Person NameUse Dropdown to select the name of the person
Qualified Vendor Mailing AddressAddress on Agency record marked as Customer
Qualified Vendor e-mail addressEmail address on Agency record marked as customer
Support CoordinatorSupport person found in the consumer’s Life Plan Support Network with role of Support Coordinator
Member NameConsumer Last Name, First Name MI
Member ID NoMedicaid Number
DDD Employment SpecialistSupport person found in the consumer’s Life Plan Support Network with role of Employment Specialist
Employer NameEmployer Name on Placement active during the Review Period Date Range
Employer Address (Street, City, State, Zip)Employment | Placement | Employer Address
Supervisor/Contact Person NameSupervisor on Placement
Member Job TitleJob Title on Placement
Member Hire DateHire Date on Placement
Weekly Work ScheduleWork Schedule on Placement
Hours Worked per WeekHours Per Week on Placement
Report Period1st Quarter (due by April 15th), 2nd Quarter (due by July 15th), 3rd Quarter (due by October 15th), 4th Quarter (due by January 15th)
Hours Member WorkedHours on Hours and Earnings record
Personal Care Services AuthorizedService Billing Authorization for PC
Personal Care Service ProvidedService hours for the Consumer for Service PC
Behavioral Support Service AuthorizedService Billing Authorization for BSS
Behavioral Support Service ProvidedService hours for the Consumer for Service BSS
Hours Job Related Support AuthorizedService Billing Authorization for HJRS
Hours Job Related Support ProvidedService hours for the Consumer for Service HJRS for the Quarter being reviewed
Member Hourly Pay RateHourly Rate on Placement

Behavioral Intervention section:

Outcome as Stated in the ISP –

Outcome with Behavior Intervention service
Progress Made, Barriers, Plan of ActionObjective questions for Objectives with Behavior Intervention service. Combine questions into a single note with a line between each note (Progress Made, Barriers, Plan of Action)

Follow-Along Services section:

Outcome as Stated in the ISP

Outcome with Follow-along service

Progress Made, Barriers, Plan of ActionObjective questions for Objectives with Follow-along service. Combine questions into a single note with a line between each note (Progress Made, Barriers, Plan of Action)

Employment Support Aide Services Log:

Date

Service Hours

Summary of Services Rendered

Employment Support Aide’s Signature

This list will display Service Records with an Activity of “Job Coaching” for the Consumer on the report.

Service Record date

Elapsed hours on the Service Record

Contents of the Service Note on the Service Record

Blank

Qualified Vendor Administrator / Designee’s NameLast Name, First Name of Person Completing Review
Qualified Vendor Administrator / Designee’s TitleJob Title of person completing review

RELATED ARTICLES

Understanding a Periodic Summary in Case Manager

Reports to List Employee Average Hourly Rates

Reports in Case Manager

Understanding Documentation and Billing Statuses in Case Manager

Working with Payments in Billing Manager

Arizona Quarterly Report 1402A Group Supported Employment Reference Information

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