COMPLETION OF THE PDW MINOTORING LOG
NAME OF PROVIDER: Name of AgencyFOR MONTH/YEAR: Month and Year this log pertains to.
PROVIDER’S SIGNATURE: Signature of person completing the form. DATE SIGNED: Date form was completed and signed.
NAME OF SERVICE COORDINATOR: Leave Blank (completed by BSHCN) DATE SIGNED: Leave blank (completed by BSHCN)
PDW PROGRAM MANAGER’S SIGNATURE: Leave blank (signed by PDW Program Manager)
DATE SIGNED: Leave Blank (Date signed by Program Manager)
PARTICIPANT’S NAME: Name of PDW Participant(s) receiving services during this calendar month.
Basic Personal Care Aide(A) Unitsauthorized by BSHCN for Basic Personal Care Aide
This number is found on the prior authorization request for T1019
(D) Units delivered by Agency for Basic Personal Care Aide
Advanced Personal Care Aide (A) Units authorized by BSHCN for Advanced Personal Care Aide
This number is found on the prior authorization request for T1019 TF
(D) Units delivered by Agency for Advanced Personal Care Aide
Authorized Nursing Visits (A) Units authorized by BSHCN for Authorized Nursing Visits
This number is found on the prior authorization request for T1001
(D) Units delivered by Agency for Authorized Nursing Visits
Waiver Attendant Care(A) Units authorized by BSHCN for Waiver Attendant Care
This number is found on the prior authorization request for S5125 U5
(D) Units delivered by Agency for Waiver Attendant Care
Private Duty Nursing(A) Units authorized by BSHCN for Private Duty Nursing
This number is found on the prior authorization Request for T1000 U5
(D) Units delivered by Agency for Waiver Attendant Care
Medical Equipment of Supplies(A) Dollar Amount authorized for Medical Equipment/Supplies
This number is found on the prior authorization request for T2028 U5 NU
(D) Dollar Amount delivered by Agency for Medical Equipment/Supply
A = Authorized units from the prior authorization B = Delivered number of units or dollars (supplies) from the prior authorization