Forms · prints · exports

The forms HHSC asks for. Column-aligned.

Sereniq renders the HHSC forms residential providers print most (4119, 4122, 3092, 8002, 3608, 3044, 4719) and tracks the rest as uploaded documents with due dates, plus the internal documents your team uses to keep the agency running. State forms carry the Texas HHS lockup with a facsimile footer. Internal documents carry Sereniq branding so a reviewer can tell what’s what at a glance.

Book a demo See the Individual Binder
A provider team reviewing printed HHSC forms together at a table
HHSC state forms

Facsimile renderers, audit-grade.

Each form ships with explicit column geometry, the Texas HHS lockup, and a “Sereniq-generated facsimile of HHSC Form NNNN” footer. What you print is what your state auditor expects to see.

Form 4119
Service Delivery Log: HCS RSS daily / HCBS SL weekly, plus a calendar-month print
Form 4122
Service Delivery Log: HCBS Host Home / Companion Care, weekly
Form 3092
Medication Administration Record: monthly grid
Form 8002
Transportation Log: per-trip record
Form 4719
Fire Drill Report: per-home safety drill record
Form 3608
Individual Plan of Care (IPC): annual HCS authorization
Form 3044
Residential Settings Review: monthly settings checklist per home
Incident Report
HHSC-style incident print, with a house-report variant
Tracked, not printed
PDP (Form 8665): Uploaded, goals typed in, annual expiry tracked. Sereniq does not generate these forms.
CNA (Form 3091) and Form 3090: Uploaded and tracked with due dates in the nursing binder. Sereniq does not generate these forms.
Delegation forms 8509, 8585, 8588: Nursing delegation paperwork, uploaded and expiry-tracked in the nursing binder. Sereniq does not generate these forms.
A facsimile, rendered

Form 4119 SDL: print-ready.

app.sereniqcare.com/reports/sdl/print
HCBS Service Delivery Log
Form 4119 · Sep 2020-E
Maple house · Houston, TX
Wk: Apr 22 – Apr 28, 2026
ActivitySunMonTueWedThuFriSat
Personal hygieneJRJRTCJRTCJRJR
Money handling-JR-TC-JR-
Community accessJR-TCJR--JR
Meal prepJRJRTCJRTCJRJR
Health & safetyJRJRTCJRTCJRJR
Staff: J. Rivera (JR), T. Cole (TC)
Supervisor signature on file · 2026-04-29
Internal documents

The packets your team uses every day.

Individual Binder

One-click state auditor packet: demographics, IRP/PDP, MAR, incidents, notes, consents

Nursing Binder

Delegation paperwork with due dates, meds, allergies, vitals, controlled-meds counts

Demographic Sheet

Single-page ER / appointment snapshot

Evacuation Plan

Per-individual emergency plan, posted in the home

Consent Packet

12 standard consents, agency-profile auto-filled

Controlled-Substance Count

Two-witness count log with discrepancy alert, printable count sheet

Blood Sugar Log

Diabetic monitoring trend print

Fire-Drill Log

Per-drill print, state auditor-ready

Grocery List / Receipt

Per-request print for the shopper

Notes packet

Date-range, individual, staff-filtered SDL packet

Individual Quarterly

Per-individual quarterly report, AI-drafted section by section

Agency Quarterly

Upload and track the agency-level HCBS quarterly for the survey-prep bundle

Incident Report (internal)

Full follow-up detail beyond the state form

Bundles & exports

One zip, ready for review.

Notes CSV export
Filterable, formula-leader neutralized for spreadsheet safety
HHSC Survey-Prep Bundle
ZIP of CSVs for an admin-chosen date range: lists for the state auditor + deficiencies for the admin. MAR and transportation logs print separately.
Payroll Pay-Period Bundle
Timesheets + manual entries + summary, normalized to your pay-period config
Related form pages
Form 4119 softwareForm 4719 fire drillsForm 3608 IPCForm 8665 PDPTransportation logsProgress notesMAR · Form 3092eMAR softwareCare plan softwareIndividual record managementHHSC survey prepCompliance bundles

Ready to see Sereniq in your homes?

Tell us about your agency and we reply within one business day.

Programs (optional)