TX HHS Form 4123. Nurse Services Delivery Log - Billable Activities
Form 4123, titled Nursing Services Delivery Log – Billable Activities, is an official documentation form used in Texas for individuals receiving nursing services under the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) programs. The form records nursing activities provided to a specific individual and serves as supporting documentation for billing, compliance, and service oversight.
This form is a practical, day-to-day tool used by nurses and providers to demonstrate that authorized nursing services were actually delivered, appropriately timed, and consistent with the Individual Plan of Care.
Purpose of Form 4123
The primary purpose of Form 4123 is to document billable nursing activities performed for a person enrolled in HCS or TxHmL services. It creates a clear record of what nursing tasks were completed, when they occurred, how long they took, and which licensed professional performed them.
The form supports:
- Accurate Medicaid billing
- Verification of service delivery
- Program compliance and audits
- Clinical oversight and continuity of care
When This Form Is Required
Form 4123 must be completed whenever a nurse provides billable nursing services under HCS or TxHmL, including both Registered Nurse (RN) and Licensed Vocational Nurse (LVN) services.
The form is required:
- For each date nursing services are delivered
- When documenting activities authorized in the IPC
- When services are provided face-to-face or via approved telehealth methods
The form is not used for non-billable activities or services provided outside the scope of authorized nursing components.
Who Is Authorized to Complete the Form
Form 4123 is completed by licensed nursing staff providing services, including:
- Registered Nurses (RN)
- Licensed Vocational Nurses (LVN)
- Specialized RNs and Specialized LVNs, when applicable
The nurse completing the form must accurately document their own services and sign with their name, title, and staff identification number.
Explanation of Key Sections
Individual and Case Information
This section identifies the individual receiving services, the service location, and the local case number. Correct identification ensures that services are properly matched to the individual’s Medicaid record.
Description of Nursing Activities
This checklist outlines specific billable nursing tasks, such as medication administration, health assessments, nursing supervision, care planning participation, and specialized training. Nurses select the activity that best describes the service provided.
Activities marked with an asterisk require additional supporting documentation, such as assessments, reports, or training records.
Service Date and Time
Nurses must record the service date, begin time, end time, total time spent, and corresponding units of service. This information directly affects billing accuracy and audit compliance.
Nurse Identification
This section captures the nurse’s name, professional title, staff ID, and nursing component (RN, LVN, Specialized RN, or Specialized LVN). Accurate classification is essential because billing rules vary by license type.
Practical Tips for Completing Form 4123
- Document services on the same day they are provided.
- Ensure times are accurate and reflect actual service delivery.
- Match documented activities to authorized IPC services.
- Attach required supporting documentation for starred activities.
- Use consistent terminology aligned with program rules.
Common Mistakes to Avoid
- Recording activities not authorized in the IPC
- Missing begin or end times
- Incorrect calculation of service units
- Failing to attach required supporting documents
- Using the wrong nursing component designation
Legal and Regulatory Context
Form 4123 is required under Texas Medicaid rules governing HCS and TxHmL nursing services. State regulations require providers to maintain detailed service delivery records to demonstrate medical necessity, protect program integrity, and ensure that billed services were actually performed. Incomplete or inaccurate logs can result in denied claims, recoupments, or compliance findings.
Real-Life Situations Where This Form Is Used
- An RN documents a face-to-face health assessment conducted during a home visit.
- An LVN records medication administration provided under physician orders.
- An RN documents supervision of an LVN and delegation training.
- A nurse logs participation in an IPC or service planning meeting.
Documents Commonly Required with This Form
- Nursing assessments and reports
- Annual Nursing Report
- Training records and competency verifications
- Care plans or implementation plans
- Supporting clinical documentation for starred activities
Frequently Asked Questions
Is Form 4123 required for every nursing visit?
Yes, it must be completed for each date billable nursing services are provided.
Can services be documented after the fact?
Documentation should be completed promptly to ensure accuracy and compliance.
Do all activities require supporting documents?
No, only activities marked with an asterisk require additional documentation.
Can LVNs complete this form?
Yes, for services within their authorized scope.
What happens if documentation is incomplete?
Incomplete logs may lead to denied claims or audit issues.
Related Forms
- Individual Plan of Care (IPC) – Form 3608
- Annual Nursing Report
- Nursing Assessment Forms
- Service Delivery Logs for Other Disciplines
Form Details
- Form Name: Nursing Services Delivery Log – Billable Activities
- Form Number: 4123
- Programs: HCS and Texas Home Living (TxHmL)
- State: Texas
- Revision Date: May 2022