Get Instructions For Completing Community Habilitation (ch) Billing Form

This guide provides a clear, step-by-step approach to completing the Community Habilitation Billing Form. By following these instructions, you can ensure your billing submission is accurate and complete, facilitating timely payments for the services provided.

Follow the steps to effectively complete the billing form online.

1. Click ‘Get Form’ button to access the Community Habilitation Billing Form and open it in your document editor.
2. Fill in 'Agency Name' with the full official name of your agency providing the services.
3. Enter the 'Federal Employer ID#' which is a nine-digit number assigned to your agency.
4. Include the name of your agency's contact, known as the DDSO, in the designated field.
5. Provide the name of the contact person within your agency who can address any inquiries related to the billing process.
6. Input the phone number of the contact person, including the area code and any necessary extensions.
7. Select one 'Community Habilitation Rate Code' by checking the corresponding box, ensuring that the group size adheres to the specified limits.
8. Choose one 'Locator Code' based on the consumer's county of residence, making sure that all participants listed share the same code.
9. Enter your eight-digit 'Provider ID#' as provided by your DDSO contact.
10. Specify the 'Month / Year of Service' during which the services were delivered.
11. Write the 'Individual Name' of the person receiving the service, ensuring to list it in Last Name, First Name format, and in alphabetical order.
12. Input the 'TABS ID' for the participant, which can be obtained from your DDSO contact if unknown.
13. Enter the total number of ¼ hour units of service received by the participant during the month.
14. Input the 'Fee' per unit, as provided by your DDSO contact.
15. Calculate and enter the 'Amount Payable’ by multiplying the number of ¼ hour units by the Fee.
16. Obtain the 'Payee Signature' from your Executive Director or their designee on the form.
17. Specify the 'Title' of the individual signing the form.
18. Enter the 'Date' when the Billing Form was completed.
19. Once you have filled all fields accurately, save changes, download, or print the form as necessary before submission.

Complete your Community Habilitation Billing Form online to ensure efficient processing and payment.