Get Form Nhep256a - New Hampshire Department Of Health And ...

Filling out the FORM NHEP256A is an important step for enrolled transportation providers to bill the New Hampshire Department of Health and Human Services for services rendered. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently online.

Follow the steps to fill out the form correctly online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your provider information. Enter your name, address, city, state, and zip code. Ensure that all information is complete and legible to avoid any payment delays.
3. Input the ETS Service Request Number. This is a 4 to 8-digit number shown on the ETS Service Approval Letter.
4. Enter the recipient’s name. Fill in the first and last name of the individual receiving transportation services, followed by their 10-digit recipient ID number (RID) assigned by DHHS.
5. Specify the dates of service. Enter the start and end dates of transportation services in MM/DD/YY format. Ensure all dates are in the same calendar month as payment is not permitted for services spanning different months.
6. Select the type of service by checking the appropriate box for multi-ride, monthly, or other services.
7. Input your provider’s Resource Number as assigned by DHHS during enrollment, starting from the leftmost box.
8. Record the total cost for the transportation services provided to the recipient for the given month.
9. Sign and date the invoice as the transportation provider to certify that the information is true and accurate.
10. Once all fields are correctly filled, review the document for completeness, then save changes, download the form, print, or share it as necessary.

Complete your FORM NHEP256A online today to ensure timely processing of your invoice!