Documentation Forms

As a provider you are required to maintain certain documentation to ensure your continued certification. Below are a SOME of the required documentation for a provider. Depending on your certification your requirements may be different. If you have questions please contact the Provider Relations Manager, Sherrie Simmons at ssimmons@knoxdd.com.

Documentation Form

Documentation Form: Per DODD rule and Medicaid Requirements you will need to complete a daily documentation sheet. This is a DODD form that has all of the required elements. You will find the “description of services” that you are responsible for throughout Discovery and the ISP.

Outcome Documentation

Providers must document both supports and outcomes they provide. This template must be used in conjunction with the service specific documentation sheet.

MUI Analysis Form

MUI Analysis Form will need to be completed each year in January and send to MEORC. MEORC will send you a reminder email about this. If you have never received an email from MEORC for this please contact Sherrie Simmons and she will ensure you are added to the mailing list. (ssimmons@knoxdd.com)

Unusual Incident Log

Unusual Incident Log Review Form- Must be completed monthly EVEN IF there are no UIRs that month.

Unusual Incident Form

This form is to be used when something unusual happens in a persons life.

8 Hour annual training

Both Independent and Agency Providers are required to maintain annual training each year. Please see the rules below for more information:

Training Requirements Agency: https://dodd.ohio.gov/forms-and-rules/rules-in-effect/5123-2-08

Training Requirements Independent: https://dodd.ohio.gov/forms-and-rules/rules-in-effect/5123-2-09

Valid CPR/First Aid

Providers that provide support to congregate settings only:

Please complete the staffing pattern form and submit to Eileen Hill (ehill@knoxdd.com) at least 45 days prior to start of the span. This form should also be completed when there are changes.

Personal Funds:

For any certified provider that provides “assistance with finances” through HPC services including payees and Shared Living Providers you must also follow the personal funds rule listed below.  Part of that requirement includes keeping a ledger of finances and reconciling them every 30 days.   

Please review the rule:

• Rule: 5123-2-07  https://dodd.ohio.gov/wps/wcm/connect/gov/91af7ef9-b221-4e46-b011-294ffe252632/5123-2-07+Effective+2022-12-01.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_M1HGGIK0N0JO00QO9DDDDM3000-91af7ef9-b221-4e46-b011-294ffe252632-oj9kP-T

Here is a template you can use and an example of how to complete

DOCTOR VISIT FORM

This form can be helpful when taking an individual to the doctor.  It’s recommended a Provider complete and keep with their records.  Share with the team as necessary.