9 -1 1
PHONE NUMBER
Dates of
Service
RECIPIENT NAME
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
Activities
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Dressing
Grooming
Bathing
Eating
Transfers
Mobility
Positioning
Toileting
Health Related
Behavior
IADLs
Meal Preparation
Light House Keeping
Laundry
Grocery Shopping
Medical Appointments
Participate in Community
Visit One
Ratio staff to recipient
Sunday
1:1
1:2
Monday
1:3
1:1
1:2
Tuesday
1:3
1:1
1:2
Wednesday
1:3
1:1
1:2
1:3
Thursday
1:1
1:2
Friday
1:3
1:1
1:2
Saturday
1:3
1:1
1:2
1:3
AM
(check AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
PM
PM
PM
PM
PM
PM
PM
(check AM/PM)
Page 1 of 4
AM
AM
AM
AM
AM
AM
MR#
Visit Two
Ratio staff to recipient
Sunday
1:1
1:2
Monday
1:3
1:1
1:2
Tuesday
1:3
1:1
1:2
Wednesday
1:3
1:1
1:2
1:3
Thursday
1:1
1:2
Friday
1:3
1:1
1:2
Saturday
1:3
1:1
1:2
1:3
AM
(check AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
PM
PM
PM
PM
PM
PM
PM
(check AM/PM)
AM
AM
AM
AM
AM
AM
Recepient/Responsible
Party Initial
Daily Total
MINUTES
Total Minutes
This Time Sheet
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
(minutes)
Total 1:1
Total 1:2
MINUTES
Total 1:3
MINUTES
After the PCA has documented his/her time and activity, the recipient must draw a line through any dates and times he/
she did not receive services from the PCA. Review the completed time sheet for accuracy before signing. It is a federal crime
to provide false information on PCA billings for Medical Assistance payment. Your signature verifies the time and services
entered above are accurate and that the services were performed as specified in the PCA Care Plan.
RECIPIENT NAME (FIRST, MI, LAST)
DATE
PCA NPI/UMPI
PCA SIGNATURE
DATE
PCA Comment
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Page 2 of 4
MR#
DHS-4691-ENG 9-11
Review PCA Provider Time and Activity Documentation for additional policy information about timesheet requirements.
Recipient Stays
Dates of Service
Page 3 of 4
Activities
For each date you provided care, write your initials next
to all the activities you provided. Your initials indicate you
provided the service as described in the PCA Care Plan. If
you provide a service more than once in a day, initial only
once. The following are general descriptions of activities of
daily living and instrumental activities of daily living.
Dressing Choosing appropriate clothing for the day,
includes laying-out of clothing, actual applying and
changing clothing, special appliances or wraps, transfers,
mobility and positioning to complete this task.
Visit One
MR#
DHS-4691-ENG 9-11
Visit Two
Daily Total
Add the total time in minutes that you spent with this
recipient for the care documented in one column.
Relationship
Add the time in minutes for all visits on this entire time
sheet and enter the total in the appropriate ratio box.
This information is available in alternative formats to individuals with disabilities by calling your PCA provider agency. TTY users
can call through Minnesota Relay at (800) 6273529. For Speech-to-Speech, call (877) 6273848. For additional assistance with
legal rights and protections for equal access to human services programs, contact your agencys ADA coordinator.
Page 4 of 4
MR#
DHS-4691-ENG 9-11