Get Hcbs Portrait Turnaround_fillable_new Mmis (10397 - Activated

Filling out the HCBS Portrait Turnaround_Fillable_New MMIS (10397 - Activated form is crucial for properly submitting claims for home and community-based services. This guide provides clear, step-by-step instructions to help you navigate the form efficiently.

Follow the steps to complete your form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your editor for completion.
2. Identify the billing period by entering the relevant start and end dates in the designated 'Billing Period' section.
3. Fill in the 'Provider Number' field with your unique identification number to ensure proper tracking of your claim.
4. Enter your name in the 'Provider Name' section, using the format: Last name, First name, Middle initial.
5. Input the 'Recipient ID Number' for accurate identification of the recipient receiving services.
6. Complete the 'Recipient Name' section in the same format as the provider name.
7. List the procedure codes applicable to your services in the 'Procedure Code' field.
8. If correcting a claim, provide the original claim number in the specified section.
9. Document the days of service by entering the 'From Day' and 'Through Day' in the designated fields.
10. Indicate the number of units provided in the 'Units' section.
11. Enter the billed amount for each service rendered in the 'Billed Amount' field.
12. Check whether this claim is a void or replacement in the respective section.
13. Read and sign the 'Certification and Agreement of Providers' to certify the accuracy of the information provided.
14. Complete the date next to your signature to finalize the submission process.
15. Once all sections of the form are completed, save your changes, then download, print, or share the form as needed.

Start filling out your HCBS Portrait Turnaround_Fillable_New MMIS (10397 - Activated form online today!