Get Statement Of Reassignment. Medicaid

Filling out the STATEMENT OF REASSIGNMENT. Medicaid form is a crucial step for outside contracted providers offering services under the School Supportive Health Services Program. This guide will provide a clear and supportive approach to completing the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the STATEMENT OF REASSIGNMENT document and open it in your preferred editing tool.
2. Begin by entering the name of the outside contracted provider at the top of the form. Ensure that the name is spelled correctly and matches any official documents.
3. In the first agreement section, confirm that the provider agrees to reassign all Medicaid reimbursements to the designated school district. This section is essential for the processing of reimbursements.
4. Next, in the second agreement section, check that the provider accepts the contracted reimbursement rates for the covered services. This reiterates that the provider understands the payment terms.
5. In the third agreement section, ensure that the provider commits to complying with all rules and policies outlined in their contract with the school district. This is important for maintaining compliance.
6. For the fourth agreement section, the provider must agree not to bill Medicaid directly for any services that the school district will bill for under the SSHSP program. This clarifies billing responsibilities.
7. Date the form in the provided section to confirm when the agreement is made. This step is important for record-keeping purposes.
8. Ensure that the outside contracted service provider signs the form in the designated signature area. This signifies their acceptance of the agreement.
9. Finally, list the school district(s) under contract for services. If there are additional districts, include them on the back of the form to keep all relevant information organized.

Complete your documents online today to ensure compliance and facilitate smooth reimbursement.