This form must be completed in English.
Audit: your billings may be audited and if you do not have this form to support what you billed and were paid for, you may have to repay the Medicaid program.
Shifts: use a new form for each shift.
Start and end time: you will enter one start time and one end time to make a record of your shift.
Service codes: these codes must match what you have been approved to perform in your AC Agreement.
Provider's signature: the actual provider of service.
| Question | Answer |
|---|---|
| Form Name | Form 470-4389 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 57 |
| Avg. time to fill out | 10 min |
| Edition | Rev 12/25 |
| Who signs | The actual provider of service |
| Maintained | During the time that the member receives services and a minimum of five years from the last claim submission date, even if you are no longer providing services |
| Other names | 470-4389, 4704389, Form 470-4389, Attendant Care Daily Service Record, AC Daily Service Record, Daily Service Record |
| Official source | Form 470-4389 (Rev 12/25), |
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