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Clinic Name* County*Choose OneBrownWinnebagoOutagamiePatient First Name* Patient Last Name* Date of Care* MM slash DD slash YYYY Services Received (Brown)*Choose OneDaily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPConsumer Education & Training Initial Family Assessment=S9445Mentoring Services=H0038Respite Care PNO Low=S5150 U1Respite Care PNO Medium=S5150 U2Respite Care PNO High=S5150 U3Counseling Social Skills Group=G0176 U9 HQServices Received (Winnebago)*Choose OneFamily/Unpaid Caregiver Supports and Services=S5110 with UK modifierRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSpecialized Child Care with U4 modifier=T2027Supportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Consumer Education=S9445Personal Supports-Attendant Care = 99509 with U2 modifierServices Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Units Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 1 hourUnits Received1 unit = 1 hourDo you have another date of service for this patient? Yes No 2nd Date of Care* MM slash DD slash YYYY Services Received (Brown)*Choose OneDaily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPConsumer Education & Training Initial Family Assessment=S9445Mentoring Services=H0038Respite Care PNO Low=S5150 U1Respite Care PNO Medium=S5150 U2Respite Care PNO High=S5150 U3Counseling Social Skills Group=G0176 U9 HQServices Received (Winnebago)*Choose OneFamily/Unpaid Caregiver Supports and Services=S5110 with UK modifierRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSpecialized Child Care with U4 modifier=T2027Supportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Consumer Education=S9445Personal Supports-Attendant Care = 99509 with U2 modifierServices Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Units Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 1 hourUnits Received1 unit = 1 hourDo you have another date of service for this patient? Yes No 3rd Date of Care* MM slash DD slash YYYY Services Received (Brown)*Choose OneDaily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPConsumer Education & Training Initial Family Assessment=S9445Mentoring Services=H0038Respite Care PNO Low=S5150 U1Respite Care PNO Medium=S5150 U2Respite Care PNO High=S5150 U3Counseling Social Skills Group=G0176 U9 HQServices Received (Winnebago)*Choose OneFamily/Unpaid Caregiver Supports and Services=S5110 with UK modifierRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSpecialized Child Care with U4 modifier=T2027Supportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Consumer Education=S9445Personal Supports-Attendant Care = 99509 with U2 modifierServices Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T201Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Units Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 1 hourUnits Received1 unit = 1 hourDo you have another date of service for this patient? Yes No 4th Date of Care* MM slash DD slash YYYY Services Received (Brown)*Choose OneDaily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPConsumer Education & Training Initial Family Assessment=S9445Mentoring Services=H0038Respite Care PNO Low=S5150 U1Respite Care PNO Medium=S5150 U2Respite Care PNO High=S5150 U3Counseling Social Skills Group=G0176 U9 HQServices Received (Winnebago)*Choose OneFamily/Unpaid Caregiver Supports and Services=S5110 with UK modifierRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSpecialized Child Care with U4 modifier=T2027Supportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Consumer Education=S9445Personal Supports-Attendant Care = 99509 with U2 modifierServices Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Units Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 1 hourUnits Received1 unit = 1 hourDo you have another date of service for this patient? Yes No 5th Date of Care* MM slash DD slash YYYY Services Received (Brown)*Choose OneDaily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPConsumer Education & Training Initial Family Assessment=S9445Mentoring Services=H0038Respite Care PNO Low=S5150 U1Respite Care PNO Medium=S5150 U2Respite Care PNO High=S5150 U3Counseling Social Skills Group=G0176 U9 HQServices Received (Winnebago)*Choose OneFamily/Unpaid Caregiver Supports and Services=S5110 with UK modifierRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSpecialized Child Care with U4 modifier=T2027Supportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Consumer Education=S9445Personal Supports-Attendant Care = 99509 with U2 modifierServices Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=99600 with U2 Modifier (1 hour code)Daily Living Skills Training (one on one)=T2017Daily Living Skills Training (2 person group)=T2017 HQ UNDaily Living Skills Training (3 person group)=T2017 HQ UPMentoring Services=H0038Units Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 15 minutesUnits Received1 unit = 1 hourUnits Received1 unit = 1 hour Δ