PROVIDER REQUEST FOR AN ADJUSTMENT ND DEPARTMENT OF HUMAN SERVICES SFN 639 (Rev. 08-2002) STATE USE ONLY (1) Reason for Request: A. No Payment Received B. Overpayment C. Underpayment D. Corrected.
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How to fill out the Printing R: 325 FORMS 00639.325 - Nd online
Filling out the Printing R: 325 FORMS 00639.325 - Nd form can initially seem daunting. This guide provides clear and concise instructions to help users complete the form online accurately and efficiently.
Follow the steps to fill out the form correctly.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the first section, select the reason for the request from the provided options, such as 'No payment received' or 'Lost check.' Ensure that you check only one box that best describes your situation.
- Enter the claim's internal control number, which is a 13-digit number, in the designated field.
- Fill in the recipient block with the following details: the recipient's I.D. number (9 digits), base ID (for state use only), patient's name, and case number (10 digits).
- Complete the provider's name section by entering your full name as it appears on official documents.
- Provide your complete address, including city, state, and zip code.
- Enter your provider number in the specified field to verify your identity.
- Indicate the date of service by filling in the 'From' and 'Thru' date fields using the MM/DD/YY format.
- Enter the total number of units serviced in the units field.
- Specify the place of service according to the service guidelines provided.
- List the procedure, ancillary, or accommodation services rendered in the designated area.
- If applicable, provide the tooth number and any modifiers that pertain to the services rendered.
- In the explanation or remarks section, clarify any issues related to the service or billing.
- Fill in the total amount billed for the services provided in the specified field.
- Lastly, enter the amount paid in the appropriate field.
- Sign the form with your provider's signature, and provide the date of signing and your telephone number.
- Once all sections are complete, save your changes. You may also download, print, or share the form as needed.
Visit the online portal to complete and submit your form now.
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