Devereux Pocono Center
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Applied Behavioral Solutions, LLC. ABA Program Activity Log
Client’s Name: ______Provider Name: ______Please Print Please Print Week Beginning: ______to Week Ending ______Service Provided: __ABA Therapy __Supervision/Assess Date of Time of # of Place of Nature of Procedure Signature of Primary Service Service hours Service Service Code Guardian/Caretaker/Teacher To - From Use Code H2019 = ABA Therapy Each Entry ** 11 office H0031 = ABA Reassessment H0032 = Initial Assessment, 12 home TX plan Development 03 H0046 = Supervision and school/commun ABA follow-up ity 98960 =
Total Hours _____
**My signature signifies that I received a service on the date/time listed above. I understand that payment for these services is from Federal and State funds, and that any false claims may be prosecuted under applicable Federal and State laws.
Signature/Degree ______Supervisor Signature______