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Recovery Works Service Authorization Tracking Log

Track service authorizations, units, and dates for Recovery Works billing.

Kura Solution

Appendix X — Recovery Works Service Authorization Tracking Log

Track service authorizations, units, and dates for Recovery Works billing.

Resident Name	RW Auth #	Service Type	Units	Start	End	CM Initials

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Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.