Get Dhmh 437 Form

Filling out the Dhmh 437 Form is an essential step for vendors requesting payment for services provided to individuals with developmental disabilities. This guide walks you through each section of the form, ensuring a smooth and comprehensive online completion.

Follow the steps to complete the Dhmh 437 Form effectively

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the vendor name in the designated field to identify the service provider.
3. Input the vendor address, including the city, state, and zip code, to ensure accurate routing of payment.
4. Fill in the state fiscal year, which reflects the financial period for this request.
5. Provide the contract award number, ensuring that it corresponds to the specific agreement in place.
6. Complete the project title section to specify the service or project related to the payment request.
7. List a contact telephone number for any queries regarding the invoice.
8. Enter the name of the director responsible for the services being billed.
9. Input the federal employer ID to confirm the business identity and tax status.
10. Clearly state the requesting period in the specified format, indicating the start and end dates.
11. Affix your signature in blue ink, confirming the accuracy of the information provided.
12. In Part A, indicate the amount of DDA award being requested and the total payment request.
13. Complete Part B by confirming that the subprovider budgets have been reviewed.
14. Ensure that a representative from DHMH signs and dates Part B as necessary.
15. In Part C, enter the amount for DDA payment, which is to be approved for processing.
16. In Part D, input the amount for DDA payment approved by the Division of Program Cost and Analysis.
17. Once all sections are complete, save your changes, download the completed form, print for your records, or share it as needed.

Complete your Dhmh 437 Form online today to ensure timely processing of your payments.