This government document is issued by Bureau for Medical Services for use in West Virginia
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https://www.google.com/url?client=internal-element-cse&cx=007317577438028001491:f-xcusnnokg&q=https://dhhr.wv.gov/bms/Programs/WaiverPrograms/ADWProgram/Documents/ADW%2520Forms%2520and%2520Instructions/Case%2520Management%2520Monthly%2520Contact%2520Instructions%252011.24.15.pdf&sa=U&ved=2ahUKEwjhgcWPx9mMAxViUqQEHcd1O0c4PBAWegQICBAB&usg=AOvVaw0YOzwIeX0UGnzwccJ6YkMQ