Get Db4b2147875b1047d473b95459df9487afc9a497e3a1122b07fceeea58cbf945.xlsx

Filling out the Db4b2147875b1047d473b95459df9487afc9a497e3a1122b07fceeea58cbf945.xlsx form is essential for submitting claims for the support of children under the Family and Children Funds program. This guide provides a detailed step-by-step process to assist users in accurately completing the form online.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. In the first field, input the legal name of the vendor that must match the name submitted via the Vendor Information Form.
3. Enter the last four digits of your Tax Identification Number or Social Security Number in the next field.
4. Provide your State Vendor ID number, which is a 6-digit number associated with your information.
5. Assign a unique invoice number with a maximum of 8 characters.
6. Fill in the date of the invoice as designated by your organization.
7. Complete the address section with your full address, ensuring it matches your Vendor Information form.
8. Indicate the type of invoice being submitted, whether it is your first submission, a rate adjustment, a re-bill, or an appeal.
9. Document the current page number and the total number of pages in this invoice.
10. Select the primary service type from the available options that reflects all services included in the invoice.
11. Enter the start and end dates for the claim period, indicating the month for which services are being billed.
12. Calculate the total of the claim by summing the total costs from all invoice pages.
13. Provide the Billable Unit Referral ID for the service referrals related to this invoice.
14. List the case ID required for processing your claim.
15. Use the designated fields to add any comments or documentation pertaining to the claim.
16. Include the billing code that correlates to the service provided.
17. Fill in the beginning date of service, which should be the first day the service was provided.
18. Complete the end date of service, marking the last day the service was rendered.
19. Indicate the number of units delivered during the claim period.
20. Provide the rate charged per unit for the service offered.
21. Calculate the total cost for each line item and ensure it is recorded accurately.
22. Sign the form in blue ink to authorize the submission of the claim.
23. Print your name as the authorized signer of the invoice.
24. Document the date on which the invoice was completed and signed.
25. Add your email address to facilitate communication regarding the invoice.
26. Include your telephone number for any clarification or resolution of billing issues.
27. Once all information is completed, save your changes, and download or print the form for your records.

Complete the necessary forms online today to ensure timely claim submissions.