|
Type
|
Service
• • •
|
|
Time In
|
Time Out
|
|
home health care agencies
|
mileage
|
|
|
AAC
|
|
XGBBJHF
|
Mautfcghcv/FXFTGCVUGHVG
|
|
QGTWFHNRF
|
WGFVHVLKBGV
|
|
WGFVHVLKBGV
|
Bati/Tajhj
|
|
ADFR
|
AUHJGCV
|
|
UHVHHJGVGJBNH
|
KMGMBVNCFD
|
|
GUIGJTCZIGUCV/JJUFRXYSZKHVFYHGVC
|
XXGBHCV
|
|
Stable / Labile
|
SDFDS
|
|
JHBVVUYHJHV
|
ADGF/LKIYCXJGIHBVJ IHYG
|
|
RYGFC
|
IUTGHBBJGU
|
|
Provider Signature
|
Participant Signature
|
