Get Child Protection Services Request For Payment - Statesdus - State Sd

This guide provides clear instructions for users on how to fill out the Child Protection Services Request For Payment form online. Understanding each section of the form is crucial to ensure accurate submissions and timely payments.

Follow the steps to complete the form successfully

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. In the Provider Identification section, fill in your control number and the date. Provide your name, address, city, state, provider number, and contract number. Ensure that all details are current and accurate.
3. In the Billing for Services Provided section, indicate the month and year for which you are billing. This will help in categorizing the payment appropriately.
4. In the Client Identification section, fill in the client's name and their identification number. This identifies the individual for whom the services were provided.
5. In the Service Information section, specify the inclusive dates of service. Include the starting and ending dates using the format provided. Indicate the number of units of service provided.
6. For each service or commodity provided, fill in the description, service code, unit price, and the amount. Sum up these amounts to obtain the total for the service information section.
7. Finally, calculate your grand total and enter it at the bottom of the form. Review all entries for accuracy.
8. Before submitting, you must declare and affirm the accuracy of the information by signing and dating the claimant signature section.
9. Once complete, you can use the button at the end to print the form for mailing or save it in your preferred format.

Take the next step and complete your documents online for swift processing.