Get Putnam County Department Of Health C2 - Form Month Amp Year

This guide provides comprehensive instructions on how to accurately complete the Putnam County Department Of Health C2 - FORM Month Amp Year online. By following these steps, users can ensure they fill out the form correctly and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the 'Month & Year of Service' in the designated space at the top of the form.
3. Complete the 'IEP Period' section by recording the start and end dates of the Individualized Education Program in the provided fields.
4. Indicate the 'Type of Service' being provided and fill in the 'Agency Name'.
5. Enter the 'Type of License/Certification' of the therapist, followed by the therapist's 'Name' and 'License#/Certification#'.
6. Fill in the 'Child Name' and 'DOB' (Date of Birth) fields accurately.
7. Detail the 'IEP Service Schedule' by specifying the frequency, duration, and method of service, and select 'Group' or 'Individual'.
8. Indicate the 'Group Size' by entering the appropriate number.
9. For each service date, enter the date, start time, end time, attendance code, caregiver initials, and amount billed.
10. Calculate the total amount billed by multiplying the number of sessions by the rate, and write the total in the 'Grand Total Claimed' section.
11. Obtain the signature of the parent or caregiver, along with the date of signing, and ensure the written authorization is included if necessary.
12. The therapist must attest to the services provided by signing above their name and filling in the required certification details, including NPI#.
13. Ensure that all required fields are completed and accurate before submitting the form.
14. Save your changes, and opt to download, print, or share the completed form as needed.

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