A. Assessments, diagnosis(es) and evaluations indicating a need for treatment and/or a physician's recommendation for treatment.

B. When applicable, a copy of the original and all updates of the individual's case or treatment plan.

C. The specific services rendered.

D. The date and actual clock time for the service rendered.

E. The name of the provider agency, if applicable, and of the person providing the service.

F. The place of service.

G. The number of units billed.

All entries must be signed or initialed and dated by the qualified professional or other provider representative who provided the service, along with the individual's title.

The documentation must be kept in the recipient's case file.

Failure by the provider to furnish records upon request may result in the imposition of sanctions. The provider must make all documents available to representatives of the Division of Medical Services Medicaid Field Audit Unit, and the Division of Youth Services, or the Division of Children and Family Services at the time of an audit. All documentation must be available at the provider's place of business. When a recoupment is necessary, the provider will be allowed only thirty calendar days after the date of the recoupment notice to submit additional documentation. Additional documentation will not be accepted if it is received after the 30<th> day.