Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to access the Proof Of Payment Affidavit Form and open it in the designated online editor.
2. In Section A, enter the claim number and claimant's full name in the respective fields. Ensure that this information matches exactly with what is on the Reimbursement Request Form to avoid denial of the submission.
3. In Section B, provide the provider's name and address. Remember that only one provider can be entered per form.
4. Move to Section C1, where you will fill out the Payment Detail Table. Enter the payor's name, check number, check date, check amount, invoice number, invoice date, invoice amount, amount paid to the invoice, and the RR number if known. Note that the payor name must match the account holder's name as it appears on the checks.
5. If the Payment Detail Table does not accommodate all necessary details, proceed to Section C2. Here, attach a separate spreadsheet containing the required information with the same header format as in Section C1.
6. In Section D, review the provider certification statement and confirm its accuracy before signing and dating the form. The signature must be in blue ink.
7. Finally, complete Section E for claimant certification. Again, review, sign, and date the statement using blue ink. If signing on behalf of another individual or entity, indicate your title and confirm your authority to sign.
8. After filling out all necessary sections, remember to save your changes. You can then download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth submission process.