TX HHS Form 4116-Dental. Dental Summary Sheet

The TX HHS Form 4116-Dental, Dental Summary Sheet, is a crucial document for tracking dental services provided to clients. This form helps healthcare professionals summarize the services rendered, including the date, cost, and client information. It should be used at the end of each month or quarter to record the services delivered.

The form requires essential information such as the service date, dollars spent, and requisition fee. The "Service Month and Year" section indicates when the services were provided, while the "Contract No." and "Contact Person" sections provide details about the client's contract and point of contact. Additionally, the "Client Care ID No." and "Name (Last, First, Initial)" sections ensure accurate identification of the client.

The form also includes a certification section where the provider must sign off on the accuracy of the information submitted. This ensures compliance with the Home and Community-Based Services/Texas Home Living Billing Guidelines. By using this form, healthcare professionals can efficiently track dental services and maintain accurate records for billing purposes.