Get Remittance Form - Give Your Life A Smile

Filling out the REMITTANCE FORM - Give Your Life A Smile is an essential task for users seeking reimbursement for services rendered. This guide will provide you with step-by-step instructions to ensure a smooth and accurate completion of the form online.

Follow the steps to fill out the REMITTANCE FORM correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the month and year of service in the designated fields labeled 'MONTH OF SERVICE' as 'MO' and 'YR'.
3. Provide your name in the 'NAME' field, ensuring it is accurately filled out as it will be used for identification.
4. Fill in your address, making sure to include the specific details such as '4TH FLOOR CIVIC CENTER, 421 MONTGOMERY STREET, SYRACUSE, NY 13202'.
5. Enter your phone number in the 'PHONE #' field for contact purposes regarding the submission.
6. In the 'VENDOR #' section, input your vendor identification number as required for processing.
7. Sign the form in the 'SIGNATURE' field to validate your request for reimbursement.
8. Date the form by filling in the 'DATE' field to indicate when the form was completed.
9. Input the child's name in the 'CHILD'S NAME' field to associate the services with the respective child.
10. Use the code key provided in the document to fill out the days of the month in the 'DAYS OF THE MONTH' section, ensuring each code corresponds to the appropriate condition (e.g., 'P' for New Placement, 'X' for Resided in the Home, etc.).
11. Optionally fill out the 'CASEWORKER'S NAME' field if applicable to your situation.
12. After completing all the required fields, review the form for accuracy and completeness.
13. Once reviewed, you can save changes, download, print, or share the form, ensuring it is submitted within the designated timelines for reimbursement.

Start filling out your document online today to ensure timely reimbursement.