Get D1217

The D1217 form is essential for claiming treatment services rendered by a single practitioner at their practice address. This guide provides a comprehensive, step-by-step approach to completing the D1217 online, ensuring users can confidently submit their claims.

Follow the steps to accurately complete your D1217 claim form.

1. Click ‘Get Form’ button to obtain the D1217 form and open it in the online editor.
2. Complete the provider details in the designated section. If your service provider does not have a provider number for the practice address where services were rendered, use the provider number from another practice address.
3. Fill in all additional sections of the D1217 form. The Pathology Inpatient Box should only be filled if all services in this claim are inpatient pathology services.
4. Attach no more than 50 service vouchers to the claim. Forward the Departmental copy for payment along with the service vouchers covered by your claim.
5. Ensure that relevant documents, such as the D904 Request/Referral, are attached to the service vouchers.
6. Review the information provided on the form, as it is necessary for provider verification and claim processing. This information will be shared with the Department of Human Services for payment processing.
7. Conclude the form by filling in the signature section. Sign your name where indicated, certifying that the information is accurate, and that all services were rendered appropriately.
8. After completing the form, save any changes. You can download, print, or share your filled-out D1217 form as necessary.

Complete your D1217 claim form online today for efficient processing.