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Home Delivered Meals — Section 7.2 Compliance
Ohio PASSPORT Waiver · Medicaid · Medicare · MyCare Ohio
Delivery Date
Driver Name
Driver Employee ID
Vehicle / Route #
| # | Consumer Full Name | Medicaid / Insurance ID | Date of Delivery | Time of Delivery | Meal Type Delivered | Temp at Delivery | Signature Status / Reason for Absence | Driver Name & Emp. ID | Driver Signature | Notes / Consumer Condition | |
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⚠️ Documentation Compliance Notice (Section 7.2)
Per Dulla Care HDM Policy Section 7.2, all delivery logs must be completed for every delivery. Records must be retained for a minimum of 6 years per Ohio Medicaid requirements. Hot meals must be ≥ 140°F and cold/refrigerated items ≤ 41°F at time of delivery. Logs must be available for review by ODM, ODA, MCO auditors, or CMS upon request. Falsifying delivery records is a violation of Ohio Medicaid regulations.
Driver / Submitting Staff Signature
Signature & Date
Supervisor / Coordinator Approval
Signature & Date
Dulla Care Home Healthcare · HDM Delivery Log · Ohio Waivered Services · Internal Use Only · Confidential