Texas HHSC Form 3625 is the monthly service-delivery log that CLASS and CFC providers use to document every service delivered to an individual, and it has to be filled out one person, one provider, one service type, and one calendar month at a time, signed by both the service provider and a separate timekeeper, and backed by detailed contact notes before any Medicaid claim goes out. Get any of those pieces wrong and HHSC can recoup the payment in full.1Texas Health and Human Services Commission. Financial Non-Compliance: Form 3625 Errors
One Form, One Combination
Each Form 3625 covers a single combination of four variables. You need a separate form whenever any one of them changes:2Texas Health and Human Services. Form 3625, CLASS and CFC Documentation of Services Delivered
- One person. Two individuals cannot share a sheet.
- One service provider. Hours worked by different providers go on different forms.
- One service type. Physical therapy and nursing each get their own form.
- One calendar month. Services that cross a month boundary roll onto a new form for the new month.
If any of those four shift, start a new form. This is the single rule most new users miss.
Filling Out the Form Section by Section
Section A: Person’s Information
Field 1 is the service month and year (only one month per form). Field 2 is the individual’s full name as it appears on the Medicaid card, Social Security card, or Form 3621 Individual Plan of Care; if those documents disagree, use the Medicaid card version. Field 3 is the person’s Medicaid number, or “Pending Waiver Eligibility” if the form is for a pre-enrollment assessment and no number has been assigned yet. Field 4, the nine-digit Social Security number, applies to CLASS applicants only and stays blank for individuals already enrolled.2Texas Health and Human Services. Form 3625, CLASS and CFC Documentation of Services Delivered
Section B: Provider Agency Information
Field 5 asks whether the agency is a Case Management Agency (CMA) or Direct Service Agency (DSA). Field 6 is the agency’s full name. Field 7 is the nine-digit contract number assigned by HHSC; for contract numbers that begin with “HHS,” enter the nine-digit provider number instead.2Texas Health and Human Services. Form 3625, CLASS and CFC Documentation of Services Delivered
Section C: Pre-Enrollment Assessment Fees
Fill this in only when you are billing a pre-enrollment assessment. Field 8 (CMA) checks Full Assessment or Partial Assessment, one or the other. Field 9 (DSA) checks Full Assessment if the DSA is billing for one.
Section D: Case Management Services
CMAs only. Field 10 is the case manager’s name. Field 11 is the checkbox indicating the documented services are ongoing case management.
Section E: Direct Services
DSAs only. Field 12 marks the method of delivery: Employee, Subcontractor, or Direct Purchase. Field 13 is the authorized service category (for example, PT or nursing). Field 14 is the service code, Field 15 the bill code. Fields 16 through 18 apply only to specialized therapies and record the authorized requisition fee amount, service code, and billing code. The Comments field is required when therapy services are delivered by telehealth or synchronous audio-visual technology; otherwise it is optional.2Texas Health and Human Services. Form 3625, CLASS and CFC Documentation of Services Delivered
Section F: Record of Time
For each day a service was delivered, log the time in and time out. Use “a” and “p” for a.m. and p.m. (9:00a, 10:30a) or military time (2100, 2230). Missing or vague time entries make billable units impossible to calculate.
Supporting Notes You Must Keep With Each Form
Form 3625 by itself will not survive a review. Each entry has to be backed by detailed contact notes, and the required contents differ by agency type.
CMA Contact Notes
Under 26 TAC §259.313, every CMA log entry needs contact notes that record the date of contact, a description of the case management activity performed, progress or lack of progress toward goals in observable and measurable terms tied to the specific goal addressed, the name of the person with whom the contact occurred, and the signature and title of the case manager.2Texas Health and Human Services. Form 3625, CLASS and CFC Documentation of Services Delivered
DSA Service Documentation
Under 26 TAC §259.363, every DSA log entry needs documentation that includes the type of service provided, the date and exact start and end times, whether the contact was by phone or in person, the name of the person with whom the contact occurred, a description of the activity performed, the signature and title of the service provider, and progress or lack of progress toward goals in observable, measurable terms tied to the specific IPP goal. The activity description is not required for non-delegated tasks performed by an unlicensed provider if the task is already documented on the IPP.3Legal Information Institute. Texas Administrative Code 26 Tex. Admin. Code 259.363 – DSA: Documentation of Services Delivered
Signatures and the Timekeeper Rule
Every Form 3625 needs two dated signatures before a claim can be submitted: the service provider’s and the timekeeper’s. The timekeeper is a designated staff person, such as a supervisor or someone else authorized by the agency, who reviews the form and signs to verify the recorded hours are accurate. The timekeeper cannot be the same person who provided the services.3Legal Information Institute. Texas Administrative Code 26 Tex. Admin. Code 259.363 – DSA: Documentation of Services Delivered
The order matters. The service provider signs first, after making the final entry. The timekeeper signs after. Submitting a claim before the timekeeper has signed is itself a compliance violation under 26 TAC §52.121.1Texas Health and Human Services Commission. Financial Non-Compliance: Form 3625 Errors
Errors That Lead to Recoupment
HHSC can recoup Medicaid funds paid on any claim where the supporting Form 3625 is incomplete or inaccurate, and under 26 TAC §52.313 the provider is liable for the full amount paid on a noncompliant claim. The agency’s financial non-compliance guidance flags these as the most common problems:1Texas Health and Human Services Commission. Financial Non-Compliance: Form 3625 Errors
- Missing service provider signature with no reason for the provider’s unavailability noted in Comments.
- Missing dates on either signature, so HHSC cannot confirm the sequence or that the claim followed verification.
- The service provider signing as timekeeper. One person cannot fill both roles, and this is one of the clearest audit red flags.
- Missing timekeeper signature, which leaves the recorded hours unverified.
- Timekeeper signature dated earlier than the provider’s, which makes the verification meaningless.
- Billing before the timekeeper has signed.
- Service dates or times that are missing or do not match the actual billable contact.
Where to Download the Current Form
The current version of Form 3625 is effective July 2025 and is available from the Texas Health and Human Services forms page in English (form 3625.pdf) and Spanish (form 3625-s.pdf).2Texas Health and Human Services. Form 3625, CLASS and CFC Documentation of Services Delivered Check the HHSC forms page before printing a batch, because HHSC updates the form periodically and using an outdated version during a compliance review creates an avoidable problem.