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Arizona Quarterly Report 1404A Reference Information

Arizona Quarterly Report 1404A Reference Information

Item Where the information is found or where it is entered
Qualified Vendor Name Agency Name on Agency record marked as Customer
Contact Person Name Use Dropdown to select the name of the person
Qualified Vendor Mailing Address Address on Agency record marked as Customer
Qualified Vendor e-mail address Email address on Agency record marked as customer
Support Coordinator Support person found in the consumer’s Life Plan Support Network with role of Support Coordinator
Member Name Consumer Last Name, First Name MI
Member ID No Medicaid Number
DDD Employment Specialist Support person found in the consumer’s Life Plan Support Network with role of Employment Specialist
Employer Name Employer Name on Placement active during the Review Period Date Range
Employer Address (Street, City, State, Zip) Employment | Placement | Employer Address
Supervisor/Contact Person Name Supervisor on Placement
Member Job Title Job Title on Placement
Member Hire Date Hire Date on Placement
Weekly Work Schedule Work Schedule on Placement
Hours Worked per Week Hours Per Week on Placement
Report Period 1st 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 Worked Hours on Hours and Earnings record
Personal Care Services Authorized Service Billing Authorization for PC
Personal Care Service Provided Service hours for the Consumer for Service PC
Behavioral Support Service Authorized Service Billing Authorization for BSS
Behavioral Support Service Provided Service hours for the Consumer for Service BSS
Hours Job Related Support Authorized Service Billing Authorization for HJRS
Hours Job Related Support Provided Service hours for the Consumer for Service HJRS for the Quarter being reviewed
Member Hourly Pay Rate Hourly Rate on Placement
Behavioral Intervention section: Outcome as Stated in the ISP – Outcome with Behavior Intervention service
Progress Made, Barriers, Plan of Action Objective 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 Action Objective 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 Name Last Name, First Name of Person Completing Review
Qualified Vendor Administrator / Designee’s Title Job Title of person completing review
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