Follow the steps to successfully complete the ITP Service Record Claim Form

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Locate the API and TPI number fields. The API will typically be filled in by the ITP provider. You must enter your TPI number, which is provided in your welcome letter once you have completed enrollment.
3. Fill in the client name, including the last name, first name, and middle initial. This section will usually be handled by the Medical Transportation Program (MTP).
4. Ensure to input the ZIP code and client telephone number, including the area code. The MTP typically fills out these fields.
5. Complete the fields for sex and birth date. Format the date as MM/DD/YYYY. The MTP will often handle these details as well.
6. Enter the client’s address, including the house number and street name. The MTP will also assist with completing some sections related to authorization numbers and the unique document ID.
7. Review the provided health-care provider details, which may require you to fill out the provider’s name and number.
8. In the affidavit section, ensure that you check the box indicating that you accept Medicaid's or the CSHCN Services Program's payment as payment in full.
9. The ITP must sign and date the form, certifying that all information provided is true and correct to the best of their knowledge.
10. Once the form is entirely filled out, save your changes, and download or print the completed document for submission.

Start filling out the ITP Service Record Claim Form online today to ensure you receive the benefits you are entitled to.