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Get Pdf Fillable Voidadjustment Form
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How to fill out the Pdf Fillable Voidadjustment Form online
Completing the Pdf Fillable Voidadjustment Form online is a straightforward process. This guide provides step-by-step instructions to help you accurately fill out the form, ensuring that all necessary information is captured correctly.
Follow the steps to complete the Pdf Fillable Voidadjustment Form online.
- Click ‘Get Form’ button to access the Pdf Fillable Voidadjustment Form and open it in your preferred editor.
- In section 1, check the appropriate block indicating whether you are submitting an adjustment or void request.
- Fill out the patient’s name in section 2. Ensure that the name matches exactly with what is on the original claim.
- Provide the patient’s date of birth in section 3a or 3b, depending on whether you are making an adjustment or a void.
- Complete the patient’s address and telephone number in section 5.
- Enter the 13-digit Medicaid ID number in section 6.
- Indicate the patient’s sex in section 7, maintaining consistency with the original claim information.
- Sections 8 to 16 should be left blank as instructed.
- In section 18a, enter the CommunityCARE authorization number if applicable, or leave it blank.
- In section 22, provide the diagnosis of the nature of illness, matching the original claim.
- Enter the attending number in section 23 if it was indicated on the original claim, or leave blank.
- Complete sections 24 through 30 following the instructions for each field as previously outlined.
- Section 31 requires the physician’s or supplier’s name, address, zip code, telephone number, and seven-digit Medicaid provider number.
- Fill in the patient's account number in section 32.
- Finally, ensure all marked (*) fields are completed to avoid the form being returned. Save your changes, download, print, or share the completed form as required.
Start completing your Pdf Fillable Voidadjustment Form online today!
Creating a fillable form in PDF can be straightforward. First, you can use a reliable platform like USLegalForms that offers a specific tool for making a Pdf Fillable Voidadjustment Form. Simply upload your document, and the tool allows you to add interactive fields easily. Once you finalize your form, you can save it, and it will be ready for others to fill out digitally.
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