How to Fill Out Texas HHSC Form 4122: Host Home/Companion Care Log

Texas HHSC Form 4122 is the weekly Host Home/Companion Care Service Delivery Log used in the Home and Community-based Services (HCS) program. You fill it out by entering the individual’s identifying information at the top, initialing each service row you performed at the end of every day, noting any incidents in the comments area, and signing and dating the form at the end of the week. The whole log must be completed within 14 calendar days of the services it documents.¹

Each form covers one person for one week, Sunday through Saturday. If you provide host home or companion care to more than one individual, use a separate Form 4122 for each.

Filling In the Header

Four fields sit at the top of the form, and getting them right is what ties the log to the individual’s Medicaid record.

Individual Name. The first and last name of the person receiving services. Not your name as the provider.
Location. The street address where the billable activity took place.
Local Case No. The individual’s local case number, assigned by your program provider. It appears in the service plan paperwork.
Week Of. The date of the first day of the week the log covers.

Initialing the Daily Grid

The body of the form is a grid. Each row names a specific activity, and each column is one day of the week. At the end of each day, go down the rows and put your initials next to every activity you actually performed with the individual that day. Leave the row blank if you did not do that activity.²

The rows fall into four groups.

Activities of Daily Living

Hands-on personal care and household tasks: bathing, dressing, personal hygiene, eating, meal planning, meal preparation, and housekeeping. If you helped the person cook dinner but did not help with bathing that day, initial the meal planning, meal preparation, and eating rows and leave the bathing row blank.

Habilitation

Skill-building work rather than routine care. The six rows cover developing and improving independent living skills, community integration, developing socially valued behaviors, using natural supports, participating in leisure activities, and IP (individual plan) skill development. These rows connect to the goals in the person-directed plan, so you need to know those goals to know which rows apply.

Assisting With

Support activities outside basic personal care: ambulation and mobility, administration of medication, reinforcing specialized therapies, transportation, supervising safety and security, monitoring health, and monitoring personal hygiene. If you drove the individual to a medical appointment and gave them their scheduled medication, you would initial the transportation and medication administration rows for that day.

Not in Home

Two rows at the bottom of the grid, “Temporary Discharge” and “Active on Leave,” handle days the individual was absent. Mark the appropriate row for any day the person was not in the home, and do not initial any activity rows for that day. Logging activities on days the individual was away is a common audit problem that is easy to avoid.

Writing in the Comments Section

A dated comments area runs across the bottom of the form. Use it to document incidents, concerns, and special events.² For each entry, write the date it happened, your initials, and a short factual description. “Individual refused lunch, ate a snack at 2 p.m.” is more useful than “had a rough day.”

Even in an uneventful week, this is the place to add context the checkboxes cannot show — a case manager visit, the reason you reinforced a particular therapy exercise, or any other detail that supports the initialed rows above.

Signing the Form

After the final day of the week, print your name on the provider name line and sign the “Host Home/Companion Care Staff Signature” line.¹ The person who signs has to be the person who actually delivered the billable activity.

If more than one provider worked with the individual during the week, each provider’s own initials have to appear in the grid cells for the days they worked, and their information should be entered in the date and initials area at the bottom.

The 14-Day Deadline

You have 14 calendar days after an activity to document it on Form 4122.¹ Entries made later than that fall outside the allowed documentation window and can be flagged as unsupported in a billing review. The practical way to stay inside the window is to initial the form every evening and sign at week’s end.

How Long to Keep the Log

The program provider keeps the completed form in the individual’s record.¹ Because Form 4122 is a Medicaid document, standard Medicaid retention rules apply. Plan to keep each log for at least six years after the end of the federal fiscal year in which the services were provided, and longer if any audit, litigation, or claim is still open.

Why Careful Entries Matter

Each column on the form represents one billable service event, so the week accommodates up to seven billable events for one individual. During an HHSC retainer payment review or billing audit, staff ask for the supporting documentation for every claimed service day. A log that is missing, incomplete, or filled in after the 14-day window can be flagged as unsupported, and HHSC does not allow additional documentation to be submitted at the exit conference.³ Thorough, same-day entries are the strongest protection against a later recoupment demand.

Where to Get the Form

Form 4122 is available as a free PDF from the Texas Health and Human Services forms library in both English (4122.pdf) and Spanish (4122-S.pdf).¹ A program provider may use its own version of the log for the same purpose, but any substitute is still treated as a Medicaid document and must capture the same information.

1
Texas Health and Human Services. Form 4122, Host Home/Companion Care Service Delivery Log
2
Texas Health and Human Services. Form 4122, Host Home/Companion Care Service Delivery Log (PDF)
3
Texas Health and Human Services. Home and Community-based Services (HCS) Program Billing Requirements (PDF)