County BillingHiddenYour Phone*Do not edit. Pre-filled for your convenience.HiddenEmail*Do not edit. Pre-filled for your convenience. 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 OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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=S9445Services Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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 minutesDo 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 OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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=S9445Services Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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 minutesDo 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 OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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=S9445Services Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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 minutesDo 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 OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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=S9445Services Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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 minutesDo 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 OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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=S9445Services Received (Outagamie)*Choose OneRespite Care=S5150 with U1 modifierRespite Care=S5150 with U2 modifierRespite Care=S5150 with U3 modifierSupportive Home Care=S5125 with U1 modifierSupportive Home Care=S5125 with U2 modifierSupportive Home Care=S5125 with U3 modifierDaily 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 minutes
