Optum SLCO Provider Biller s Training. Updated June 15, 2017 Optum Salt Lake County
|
|
|
- Mae Fields
- 6 years ago
- Views:
Transcription
1 Optum SLCO Provider Biller s Training Updated June 15, 2017 Optum Salt Lake County
2 Overview Provider Connect Search Window Enhancement Discharge Form MHER Updates Claim Submissions Emergency indicator Original Claim vs. Replacement claim vs. Voided claim Proprietary and Confidential. Do not distribute. 2
3 Provider Connect Client Search The client search window in Provider Connect has been enhanced to include the option to search for only Medicaid ID. Effective 07/01/17, Medicaid ID is required when using the Add Client/New Client Search form. Tip: Be sure to include the leading zero. The search result window will display the corresponding client record. Proprietary and Confidential. Do not distribute. 3
4 Provider Connect Client Search con t In the event that the client could not be found, please select the button Create Admission for New Client. Enter client demographic information into form, along with admission date and time. Click Save Admission at the bottom of the page. Please Note: The Medicaid ID will populate from data entered in the search window. Proprietary and Confidential. Do not distribute. 4
5 Provider Connect Client Discharge A discharge form has been added to Provider Connect for providers to report their clients have discharged from service. The form can be found on the left navigation bar All active authorizations for the client will be updated to end on discharge date, during the monthly authorization evaluation processing. Proprietary and Confidential. Do not distribute. 5
6 Provider Connect - Mental Health Event Record All clients that are actively receiving MH services must have their mental health event record updated a minimum of every 90 days. Race codes have been expanded to further clarify categories Question Allowable Response Special Instructions Race Alaskan Native American Indian Asian Black Native Hawaiian or Pacific Islander White Two or more races Other single race Alaska Native: Aleut, Eskimo, Indian (origins in any of the original people of Alaska. American Indian: Does not include Alaska Native. Origins in any of the original people of North America and South America (including Central America) and who maintain cultural identification through tribal affiliation or community Attachment. Asian: Origins in any of the original people of the Far East, the Indian subcontinent or Southeast Asia including Cambodia, China, India, Japan, Korea, Malaysia, Philippine Islands, Thailand, Vietnam Black African American: Origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander: Including Hawaii, Guam, Samoa or other Pacific Islands. White: Origins in any of the original people of Europe, North Africa or the Middle East. Clients of Hispanic ethnicity are typically coded as white. Two or More Races: Use this code when individual identifies with more than one of the above categories. Other Single Race: Used when a client is not classified in any other category or whose origin group, because of are custom, is regarded as a racial class distinct from the above categories. Please Note: Do NOT use this category for clients indicating multiple races. Tobacco question enhanced to include e-cigarettes/vaping. Question Allowable Response Special Instructions Tobacco Use Never smoked/vaped Former smoker/e-cig User Current some-day smoker/e-cig User (Occasional User) Current every-day smoker/e-cig User Smokeless tobacco only (In last 30 days) This field is used to track the nicotine (cigarettes, e-cigarettes and smokeless tobacco products) usage. If client uses cigarettes/e-cig AND smokeless tobacco, only keep track of the frequency of cigarette/e-cig use.. This required variable is to be updated at the 6-month case review, when a change is indicated and at discharge. Proprietary and Confidential. Do not distribute. 6
7 Provider Connect - Mental Health Event Record con t Compelled for treatment and Compelled and justice risk changes Question Allowable Response Special Instructions Criminal Court Compelled for Treatment Yes No This required variable is to indicate if a client has been court compelled for treatment by a criminal court. This includes: Plea in Abeyance (Including Drug Court) Diversion Programs Probation/Parole Condition (including DORA) Criminal Court Order Release from jail condition Sentence Please Note: If a Probation/Parole Officer "suggests" they go into treatment, and expects them to comply with the suggestion, then it is compelled.. This variable needs to be updated anytime it changes or at least every 90 days Criminogenic Risk Level Low Risk Not Low Risk (moderate/high risk) Not collected This variable is determined by the validated tool approved in your Justice Certification Plan. It is required for all clients that are reported as compelled to treatment. Proprietary and Confidential. Do not distribute. 7
8 Claim Submissions Emergency Services All services (claim lines) where the service meets emergency criteria defined on previous page should be coded as Y in the emergency indicator field. An emergency service is defined as: An hourly service provided on an immediate or unscheduled basis and deals with a psychological emergency of a patient. These activities are available on a 24-hour basis, including during regular work hours. Routine informational calls handled by crisis staff are not to be reported as crisis/emergency only those calls involving counseling. This activity should also not be confused with a crisis intervention approach, which may span several sessions and be reported as one of the scheduled outpatient activities. Examples of behaviors targeted by crisis/emergency services are: Suicide attempts Violent family fights Panic attacks Uncontrollable behavior Behaviors that are a threat to self or others. Emergency services may include telephone counseling and referral services. Face-to-face assessments or evaluations for crisis should also be included here. Proprietary and Confidential. Do not distribute. 8
9 Claim Submissions Emergency Services con t Paper Claims Field 24C on CMS1500. Populate Y if service is emergency. Proprietary and Confidential. Do not distribute. 9
10 Claim Submissions Emergency Services con t 837 (EDI) transactions Loop 2400, Segment SV109 See page 34 of 837P Professional companion guide Proprietary and Confidential. Do not distribute. 10
11 Claim Submissions Original, Replacement, Void Optum SLCo allows for the submission of replacement and void claims via 837. All original claims (freq code 1) are subject to 90-day timely filing rule. 90-days is calculated from date of service or date eligibility granted, whichever is later. Replacement claims (freq code 7) allow for 365-day clean up. Allows for the correction of a service that was previously submitted. 365-days is calculated from date of service to claim submission date. Ensures that clean-up/replacement claim is not inappropriately denied for 90-day timely filing. Void claims (freq code 8) allow for 365-day clean up. Allows for a provider to electronically communicate to Optum SLCO that a service should not have been approved. Please Note: Claims that were originally denied for exceeding 90-day timely filing, are not eligible for 365-day clean up. Proprietary and Confidential. Do not distribute. 11
12 Claim Submissions Original, Replacement, Void con t A claim can only be replaced once. Therefore, if a claim was denied multiple times, each replacement claim must be reference the claim that immediately proceeded it. For example: Claim #1: Original claim submitted. Claim denied because service was not authorized. Payer claim control number Claim #2: Replacement claim submitted. Claim denied because the client does not have SLC Medicaid eligibility. Payer claim control number Claim #3: Replacement claim submitted. Claim approved because client paid spend down and now has eligibility. Payer claim control number In the example above, claim #2 is replacing claim #1 and claim #3 is replacing claim #2. So logistically, when submitting #3, the payer claim control number from #2 is required as this tells the system what claim is being replaced. Proprietary and Confidential. Do not distribute. 12
13 Claim Submissions Original, Replacement, Void con t Optum SLCo allows for the submission or replacement claims via 837 submission. Loop 2300, Segment CLM. Element 05-3 Loop ID Segment ID Element ID Segment or Element Name Required=R Situational=S OH Salt Lake County Instructions For original submissions use value: 1 Original OptumHealth will allow for submission of electronic corrections or voids to a previously paid claim. Acceptable Values: 2300 CLM 05-3 Claim Frequency Code R 7 Replacement 8 Void PLEASE NOTE: The OptumHealth SLCo Claim Number assigned to the claim that is being voided ( 8 ) or replaced ( 7 ) must be reported in the associated 2300 ORIGINAL REFERENCE NUMBER REF02. Proprietary and Confidential. Do not distribute. 13
14 Questions?
15 Contract and Provider Connect Questions Optum SLCo Network prompt #5 Thank you!
CITY OF CALISTOGA DOWN PAYMENT ASSISTANCE PROGRAM LOAN APPLICATION
DOWN PAYMENT ASSISTANCE PROGRAM LOAN APPLICATION Date Applicant s Name Phone Residence Address Home City, State, Zip Code Phone Mailing Address (If different) FAMILY INFORMATION Applicant or Co-Applicant
Last Name First Name Middle Initial ADDRESS Street City County State Zip
APPLICATION FOR EMPLOYMENT Kolberg-Pioneer, Inc. An Equal Opportunity Employer (HRF-002-03 01/16) This application is valid for the calendar year of 2018. Kolberg-Pioneer, Inc. will provide the Social
Voluntary Information for Equal Employment Opportunity Purposes
Voluntary Information for Equal Employment Opportunity Purposes Below is a Voluntary Information Sheet that we would like you to complete. It will be used for Equal Opportunity purposes only. The requested
Employment Application
Employment Application To Applicant Instructions We appreciate your interest in our company and we are interested in reviewing your qualifications for our current open positions. To make this the best
Volunteer Driver Application
Volunteer Driver Application PLEASE PRINT This application will be used to establish your eligibility as a volunteer driver for the Drive to Help program. The information you provide helps us assure you,
TRADE ACT PARTICIPANT REPORT
TRADE ACT PARTICIPANT REPORT REVISED PARTICIPANT RECORD LAYOUT Field Number Field Name Guidelines and Comments Section I: Identification and Characteristics of Applicant 1 I.1. State name Record the full
Mobiloil Federal Credit Union Employment Application
Mobiloil Federal Credit Union Employment Application It is our policy to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age,
WAITLIST APPLICATION CHECK LIST
3550 VILLA LANE NAPA, CALIFORNIA 94558-3436 (707) 251-8077 WAITLIST APPLICATION CHECK LIST Thank you for your interest in Silverado Creek rental housing. For your convenience we ve summarized below the
REVOLVING LOAN FUND POLICY
REVOLVING LOAN FUND POLICY The purpose of this policy is to provide guidance regarding loans from a revolving loan fund (RLF) to private and public entities for projects that benefit the community. Nothing
American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight) Analytics Data Dictionary
10/23/2018 American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight) Analytics Data Dictionary Disclaimer: This data dictionary covers the data elements found within the American
Nutrition Services Division DCH 06 (REV. 8/2018) PAGE 1 of 6 MEAL BENEFIT FORM FOR PROVIDERS
PAGE 1 of 6 MEAL BENEFIT FORM FOR PROVIDERS Complete, sign, and return this form to your day care home (DCH) sponsor. If you need assistance completing this form, call: (213) 380-3850 Name of DCH provider:
Application for Employment
Position Sought: Community Transit of Delaware County, Inc. 206 Eddystone Avenue Suite 200 Eddystone, PA 19022-1594 Application for Employment Date: (Last) (First) (Middle Name) (Street Address) (City)
State Employees Credit Union Application for Employment
State Employees Credit Union Application for Employment Note: Application must be handwritten. Do not type. We appreciate your interest in our organization. Please complete the application as fully as
MEAL BENEFIT FORM FOR PROVIDERS
PAGE 1 of 5 MEAL BENEFIT FORM FOR PROVIDERS Complete, sign, and return this form to your day care home (DCH) sponsor. If you need assistance completing this form, call: Juanita Royal (916) 344-6259 Ext.
ESKATON HAZEL SHIRLEY MANOR San Pablo Avenue, El Cerrito, CA PH: (510) FAX: (510) TDD: (800)
RCVD BY DATE TIME ESKATON HAZEL SHIRLEY MANOR 11025 San Pablo Avenue, El Cerrito, CA 94530 PH: (510) 232-3430 FAX: (510) 232-1056 TDD: (800) 735-2922 www.eskaton.org APPLICATION FOR HOUSING PLEASE PRINT
Personal Information: *Please complete all information. Use ink and print clearly, so we can get to know you! Last Name:
In order to be hired, you must be willing to submit to a physical and urinalysis screening. Application is valid for thirty (30) days from Date Received Today s Date: Bausch-American Towers Attn: HR Manager,
MedStart-5. Application for Assistance
MedStart-5 Application for Assistance Transportation Meals Assistance Utilities Co-Payments Adult Home Care Lab Testing For application help, contact us at 1-888-842-2654 To apply for benefits, follow
To determine your eligibility for the program, the following documentation must be completed and submitted:
Dear Applicant, As a participating jurisdiction in the St. Charles Urban County, the City of St. Peters will administer a St. Peters Urban County Home Improvement Loan Program (H.I.L.P) once federal funding
GEORGIA DEPARTMENT OF EDUCATION (GDOE) Administrative Technology Division. FY 2017 CPI Data Collection Data Elements Glossary
GEORGIA DEPARTMENT OF EDUCATION (GDOE) Administrative Technology Division FY 2017 CPI Data Collection Data Elements Glossary CPI DATA ELEMENTS GLOSSARY Glossary ANNUAL CONTRACT SALARY FOR CERTIFIED ANNUAL
July Dear Provider:
, Inc. Our Mission is to encourage and support the success and well-being of children, families and the child care community... July 2018 Dear Provider: To qualify for tier I reimbursement for meals served
Exact title of the position for which you are applying. Applications will only be processed for current vacancy. (Last) (First) (Middle)
EFFINGHAM COUNTY BOARD OF COMMISSIONERS Employment Application 601 North Laurel Street Springfield, Georgia 31329 hr@effinghamcounty.org Telephone: 912-754-2104 Fax: 912-754-8402 We are an equal opportunity/drug
Affordable/Income Restricted Housing Lottery Application
Affordable/Income Restricted Housing Lottery Application Development Name: Weinberg House Development Address: 132 Chestnut Hill Ave, Brighton MA 02135 Deadline to Submit Application: September 7, 2018
WELCOME TO TORRANCE MEMORIAL PHYSICIAN NETWORK
WELCOME TO TORRANCE MEMORIAL PHYSICIAN NETWORK Thank you for choosing us as your healthcare provider. We have enclosed instructions for filling out the paperwork that will be necessary for your first visit.
Chapter 10 SINGLE-ADDRESS HOMEOWNER REHAB ACTIVITIES
Chapter 10 SINGLE-ADDRESS HOMEOWNER REHAB ACTIVITIES This chapter explains how to set up, fund, draw funds for, and complete homeowner rehabilitation activities that are carried out at a single location.
SOUTH TEXAS HEROES HOUSING ASSISTANCE (STHHA) APPLICATION
APPLICANT CO-APPLICANT Rental Emergency Asst. Utility Pmt. Supportive Services SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER HA HP DV/SA RELOCATION EVICTION OTHER CURRENT ADDRESS APT OR LOT # TELEPHONE
Small Business Enterprise Program
Small Business Enterprise Program Registration & Roster Enrollment Registration Does NOT Pre-Approve You (The City may use this information to develop bid lists, contract lists and reports. Prime contractors
Preliminary Rental Application
OP 241 For Office Use Only Rec d Time Rec d Initials Preliminary Rental Application Please note that this is a preliminary application and gives no lease or rent rights. Community Office ( ) Unit Size
(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
PATIENT INFORMATION (Please Print using Black or Blue Ink) LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY: STATE: ZIP: SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER RACE (OPTIONAL):
Other, please explain
: General Information First name: Middle initial: Last name: of Birth: Street address: City State Zip Marital Status: Single Married Other Email Address: Cell Phone: Cell phone provider: Home Phone: Center
Patient Registration Form
Patient Registration Form MRN #: Patient Name: Provider: Sort ID: DOB: Date: Address Home Phone Cell Phone Work Social Security Number Date of Birth Male Female E-mail Address Is your visit today due to
MASSACHUSETTS WATER RESOURCES AUTHORITY Employment Application
MASSACHUSETTS WATER RESOURCES AUTHORITY Employment Application Massachusetts Water Resources Authority is an Equal Opportunity/Affirmative Action Employer. MWRA does not discriminate on the basis of race,
APPENDIX A. Definition of Terms
APPENDIX A. Definition of Terms Appendix A provides explanations and definitions useful to understanding the 2015 Public Works Disparity Study. The following definitions are only relevant in the context
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date. Mailing Address City State Zip. Street Address City State Zip
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date Mailing Address City State Zip Street Address City State Zip Home Phone Cell Phone Employer Name (for work comp only) Employer
Patient Registration Form Adults
Patient Information Patient Registration Form Adults For Office Use Only: Visit Date: Initials: Patient s Last Name First Middle Initial Date of Birth Sex Male Female Race* (see reverse for more detailed
BPO Vendor Packet. Please or fax your completed application back to ISGN:
BPO Vendor Packet Thank you for your interest in becoming an ISGN Vendor Partner. Please complete the following documents so we may successfully set up your account: 1. Vendor Application 2. Affiliate
Revised Southern California Edison Company Page 1
Diverse Business Enterprise (DBE) Subcontracting Commitment and Reporting Requirements I. Overview It is Edison s goal to provide diverse business enterprises ( DBEs ), such as women, minority and service-disabled
APPLICANT INFORMATION Applicant's Full Name (First M.I. Last) Social Security Number Citizenship
APPLICATION CREDIT REQUESTED Application Date Application ID Amount Requested Term Product Specific Purpose of Loan We intend to apply for Joint Credit. Borrower Co-Borrower What branch would you like
WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU
DATE: / / WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU Richard L. Corbin, DPM, FACFAS PATIENT NAME: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: / / D.O.B: / / STREET ADDRESS: CITY:
California State University Channel Islands Ironwood Hall One University Drive Camarillo, CA (805)
Division of Business and Financial Affairs Procurement & Logistical Services Service Provider/Contractor/: Thank you for your interest in doing business with California State University Channel Islands
2017 Audit of the City s Gender and Ethnic Diversity Report # January 2018
2017 Audit of the City s Gender and Ethnic Diversity Report # 2018-01 Jorge Oseguera, City Auditor Sean Arnold, Auditor The City of Sacramento s can be contacted by phone at 916-808-7270 or at the address
LOCAL CHURCH REPORT TO THE ANNUAL CONFERENCE
Instructions for Table 1 1 Enter here the figure reported on Line 9 of last year s Local Church Report. Do not use this line to correct the previous year s report. Corrections, if necessary, may be made
ANTI-DISCRIMINATION POLICY of the SCHOOL DISTRICT OF PHILADELPHIA ADOPTED NOVEMBER 14, 2007
ANTI-DISCRIMINATION POLICY of the SCHOOL DISTRICT OF PHILADELPHIA ADOPTED NOVEMBER 14, 2007 SECTION 1. THE POLICY It is the policy of the School District of Philadelphia (the "District") acting through
Name Last First M.I. Head of Household
PROGRAM APPLICATION Name First Last M.I. Street Address Apt. # City State Zip Phone Cell Email: Household Composition Name Last First M.I. Relationship Head of Household of Birth Age Social Security #
LOCAL CHURCH REPORT TO THE ANNUAL CONFERENCE
Instructions for Table 1 1 Enter here the figure reported on Line 9 of last year s Local Church Report. Do not use this line to correct the previous year s report. If possible, this line should be provided
This is a PDF version of the 2019 Law survey. To complete the survey, follow this link to the online form.
This is a PDF version of the 2019 Law360 400 survey. To complete the survey, follow this link to the online form. Welcome to the 2019 Law360 400 survey! The answers to these questions will be used for
Hardee County Board of County Commissioners Equal Employment Opportunity (EEO) Self-Identification Form (completion of this form is voluntary)
Please submit to: Hardee County Board of County Commissioners HR Department 205 Hanchey Road, Wauchula, Florida 33873 Phone: (863) 773-2161 Hardee County Board of County Commissioners Equal Employment
All Characteristics Report - Data Entry Form
All Characteristics Report - Data Entry Form All Characteristics Report A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained. This is an unduplicated count
Budget and Audit Committee Report 915 I Street, 1 st Floor Sacramento, CA
Budget and Audit Committee Report 915 I Street, 1 st Floor Sacramento, CA 95814 www.cityofsacramento.org File ID: 2018-00051 January 16, 2018 Discussion Item 03 Title: City Auditor s 2017 Audit of the
Subject: Referral Response: Berkeley Municipal Code Section Amendment Related to Commissioners
Page 1 of 7 Office of the City Manager CONSENT CALENDAR July 25, 2017 To: From: Honorable Mayor and Members of the City Council Dee Williams-Ridley, City Manager Submitted by: Mark Numainville, City Clerk
Performance Outcomes System Reports Report run on August 3, 2016
Performance Outcomes System Reports Report run on August 3, 26 Background Three reports will be created during each new reporting period. The reports that will be produced are as follows: statewide aggregate
PATIENT REGISTRATION FORM Patient Information. Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: Address: Street
Today s Date: Patient ID # [for office use only] Referring Physician PATIENT REGISTRATION FORM Patient Information Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: For Minors please
AN EQUAL OPPORTUNITY EMPLOYER DATE SOCIAL SECURITY NUMBER CITY CITY IN CASE OF EMERGENCY NOTIFY: NAME RELATIONSHIP TELEPHONE NUMBER ( ) YES NO
Please fill out the application in its entirety FIRST MIDDLE LAST AN EQUAL OPPORTUNITY EMPLOYER DATE SOCIAL SECURITY NUMBER 20 PRESENT STREET CITY STATE ZIP PERSONAL PERMANENT TELEPHONE NUMBER HOME STREET
1. Who is entering the data into this survey? Note: This should be the name of the Navigator, NOT the name of the client.
Survey Instructions Please complete this survey within 60 days of a client beginning Navigator services. In order to complete this survey you will need to interview the client. To conduct the interview
Patient Registration
Patient Registration Please check Primary Home Work Cell phone Gender SSN E-mail Address Driver s License M F Marital Status Preferred Contact Ethnicity Race Married Single Divorced Separated Widowed Life
APPLICATION FOR EMPLOYMENT
APPLICATION FOR EMPLOYMENT Morgan-Keller is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any other characteristic
Application for Transitional Housing
United Ministries, Inc. EARLS PLACE 1400 E. Lombard Street Baltimore, Maryland 21231 Application for Transitional Housing Today s Date: General Information How did you hear about Earl s Place? First Name:
CATHOLICS FOR HOUSING, INC. (CFH) CFH NOVA DPA APPLICATION CHECK LIST JANUARY 2017
CFH NOVA DPA APPLICATION CHECK LIST JANUARY 2017 Application Package Application completed and signed Authorization to Release Information First Time Homebuyer Affidavit Employment / Income Verification
MORTGAGE SUBMISSION VOUCHER
MORTGAGE SUBMISSION VOUCHER Purpose: Competed by: Submission Requirement: This form lists all the Mortgage data for each loan to be submitted for purchase. The Administrator uses the data from the Mortgage
APPLICATION FOR STATE CERTIFICATION
APPLICATION FOR STATE CERTIFICATION Thank you for your interest in applying for state certification. We ask that you carefully complete each question. If a question is not applicable, simply answer that
MARYLAND HOSPITAL CREDENTIALING APPLICATION
Error! Name STATE OF MARYLAND DHMH MARYLAND HOSPITAL CREDENTIALING APPLICATION Please type or print. Incomplete or illegible applications will not be processed. I. PERSONAL INFORMATION Name (Last, First,
1. PLEASE READ CAREFULLY Applications will be processed in order of date and time received.
Dear Applicant: Thank you for applying for tenancy at W a t e r s E d g e C r e s c e n t 1 located in Elizabeth, New Jersey 07206. Please complete this application in accordance with the following application
A - EMPLOYEE INFORMATION SUBMISSION AND CERTIFICATION
Office/Client Number New Employee Packet Employer Information: Choose your option for submitting employee information. For detailed instructions for these options, refer to the PEO New Employee Packet
SPECIAL PROVISION. Disadvantaged Business Enterprise in State Funded Construction
1993 Specifications SPECIAL PROVISION Disadvantaged Business Enterprise in State Funded Construction The purpose of this Special Provision is to carry out the Texas Department of Transportation's policy
HCSIS Individual Clearance Screen HCSIS Field Name
HCSIS Individual Clearance Screen Last Middle Initial First Date of Birth Gender Citizenship Ethnicity Race Social Security Number Enter the last name of the CHIPP participant. Enter the middle initial
California Department of Education, May 2016 School Year 2016-2017 Sunrise Middle School Application for Free and Reduced-Price Meals: State Meal Program Complete one application per household. Read the
NORTH TEXAS ARRHYTHMIA ASSOCIATES, PA
Demographic Information Name of Birth Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary
To Enroll in CareOregon Advantage, Please Provide the Following Information: ( ) Please Provide Your Medicare Insurance Information
PLAN USE ONLY: Received Date Time Enter Date ES Submit Date ES To Enroll in CareOregon Advantage, Please Provide the Following Information: Please check which plan you want to enroll in: CareOregon Advantage
SPECIAL PROVISION. Disadvantaged Business Enterprise/Historically Underutilized. in State Funded Construction
1993 Specifications SPECIAL PROVISION Disadvantaged Business Enterprise/Historically Underutilized Business in State Funded Construction The purpose of this Special Provision is to carry out the Texas
NORTH TEXAS DIABETES & ENDOCRINOLOGY OF PLANO
Demographic Information Name Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary Phone
APPLICATION FOR ADMISSION
803 Lyon Street Des Moines, IA 50309 Phone: 515-244-0370 Fax: 515-244-3707 harborofhopeia@gmail.com Harbor of Hope - Iowa Alcohol & Substance Abuse Recovery House APPLICATION FOR ADMISSION This application
Washington, DC. HFA Performance Data Reporting- Borrower Characteristics
HFA Performance Data Reporting- Borrower Characteristics QTD Cumulative 1 Unique Borrower Count 2 Number of Unique Borrowers Receiving Assistance 19 767 3 Number of Unique Borrowers Denied Assistance 5
By signing this Signature Page, the Offeror represents and certifies compliance with the attached Certifications and Representations.
By signing this Signature Page, the Offeror represents and certifies compliance with the attached Certifications and Representations. The full text of a solicitation provision may be accessed electronically
A. FORM W-9 REQUEST FOR TAXPAYER IDENTIFICATION NUMBER (TIN) AND CERTIFICATION (Please type or print) Legal Name of Entity (must match TIN)
VENDOR STATEMENT OF BUSINESS AND LEGAL RELATIONSHIPS The Railroad is required by IRS guidelines to obtain a Form W-9 from all payees. This substitute form is designed to fulfill the Form W-9 information
PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP
PATIENT INFORMATION PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL
Primary Care Physician Cardiologist Referring Physician PROTECTED HEALTH INFORMATION AUTHORIZATION
DEMOGRAPHIC INFORMATION Name Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary Phone
Duplicate Encounter Avoidance Guidelines
Duplicate Encounter Avoidance Guidelines MCO Encounter Improvement Initiative Meridian Health Plan Institutional Billing Guidelines HFS considers a duplicate claim as more than one claim submitted to a
Ohio Civil Service Application forstateandcountyagencies
Ohio Civil Service Application forstateandcountyagencies GEN-4268 (REVISED 01/12) 06/08) ThestateofOhioisanEqualOpportunityEmployerandproviderofADAservices. State is an Opportunity Employer and provider
Vendor Information Form
NEW YORK STATE HOUSING FINANCE AGENCY HOUSING TRUST FUND CORPORATION NEW YORK STATE AFFORDABLE HOUSING CORPORATION STATE OF NEW YORK MORTGAGE AGENCY STATE OF NEW YORK MUNICIPAL BOND BANK AGENCY TOBACCO
hera sambaziotis, md, mph, facog & martina frandina, md, facog anthony bozza, md, facog
hera sambaziotis, md, mph, facog & martina frandina, md, facog anthony bozza, md, facog PLEASE FILL OUT ALL INFORMATION COMPLETELY AND ACCURATELY Failure to do so may give you a larger out of pocket expense
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
2018:IIIQ Nevada Unemployment Rate Demographics Report*
2018:IIIQ Nevada Unemployment Rate Demographics Report* Department of Employment, Training & Rehabilitation Research and Analysis Bureau Dr. Tiffany Tyler-Garner, Director Dennis Perea, Deputy Director
City of Modesto Homeowner Rehabilitation Program
City of Modesto Homeowner Rehabilitation Program Overview The City of Modesto s (City) Homeowner Rehabilitation Program is designed to repair or eliminate health and safety hazards in residential properties,
APPLICATION FOR SMALL BUSINESS LOAN
APPLICATION FOR SMALL BUSINESS LOAN Please return this form with the applicable credit report fees. We cannot consider any loan request that is not accompanied by a completed application. COMPANY INFORMATION
Application for Admission and Rental Assistance Section 8 Elderly or Disabled
Property Name: Sorrento Tower Telephone: (619) 276-1775 : 2875 Cowley Way Fax: (619) 276-4527 2: San Diego, CA 92110 TTD/TTY: 711 National Voice Relay Email: info@sorrentotower.com For Office Use Only:
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
Financial Assistance Guidelines
Financial Assistance Guidelines The Pomona Valley YMCA provides financial assistance to all who want to participate in the YMCA programs based on eligibility and availability of funds. Every application
City of Modesto Homebuyer Assistance Program
City of Modesto Homebuyer Assistance Program Overview The City of Modesto s (City) Homebuyer Assistance Program provides deferred-payment; lowinterest loans to assist low income families purchase a qualified
HOUSING AUTHORITY OF THE CITY OF MILWAUKEE (HACM)
HOUSING AUTHORITY OF THE CITY OF MILWAUKEE (HACM) PRIME CONTRACTOR FORMAL CONTRACT PROVISIONS FOR SUBCONTRACTING WITH EMERGING BUSINESS ENTERPRISES* FEDERAL DOLLARS NON-FEDERAL DOLLARS Where Federal dollars
Findings from Focus Groups: Select Populations in Dane County
W ISCONSIN STATE PLANNING GRANT Briefing Paper 3, September 2001 Findings from Focus Groups: Select Populations in Dane County Wisconsin is one of 20 states that received a grant in 2000-01 from the Health
A Medicare Information
Alaska Medicare Supplement Enrollment Application for Plans A, F, High Deductible F, G and N P.O. Box 327, MS 295 Seattle, WA 98111-9220 1-888-669-2583 Fax: 425-918-5278 You are eligible to apply for a
Hospice Utilization Report Definitions. Table of Contents. Patient Census
Table of Contents Patient Census Page Patients by Gender 2 Patients by Race 2 Patients by County 3 Patients by Primary Diagnosis 4 Admitted Patients by Referral Source 5 Not Admitted Patients by Referral
HUD-9902 Desk Guide. Don't Forget! HUD-9902 Category. How to Complete
Don't Forget! Data is CUMULATIVE! For example, your Q3 report should include all households served from Q1 - Q3. If your agency received HUD approval mid-way through the fiscal year, you should still report
5010 Upcoming Changes:
HP Systems Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S 5010 Upcoming Changes: 834 Benefit Enrollment and Maintenance Transaction Based on Version 5, Release 1 ASC X12N 005010X220 Revision
Homebuyer Application
Homebuyer Application Follow these steps to submit an application to purchase Montana Street Homes As part of this application you will need to: Provide copies of pay stubs and bank statements for the
SELECTED INDICATORS FOR WOMEN AGES 15 TO 44 IN KITSAP COUNTY
SELECTED INDICATORS FOR WOMEN AGES 15 TO 44 IN KITSAP COUNTY TABLE OF CONTENTS Introduction page 2 Data Details page 3 Demographic Indicators page 4 Pregnancy Indicators page 5 Socioeconomic Indicators
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
NAME (FIRST) (MIDDLE) (LAST) SOCIAL SECURITY NO. (OPTIONAL) DATE OF APPLICATION
Bristol Bay Area Health Corporation P.O. Box 130 Dillingham, Alaska 99576 Phone: 1-907-842-5201 --- In Alaska: 1-800-478-5201 Fax: 1-907-842-9251 --- Email: recruitment@bbahc.org BBAHC enforces a drug
City of Coachella First Time Home Buyer Program
City of Coachella First Time Home Buyer Program The City of Coachella s (City) First-time Homebuyer Down Payment Assistance Program provides deferred-payment, low-interest loans to assist low income families
Home Mortgage Disclosure Act (HMDA) 2014 FIS and/or its subsidiaries. All Rights Reserved.
Home Mortgage Disclosure Act (HMDA) 2014 FIS and/or its subsidiaries. All Rights Reserved. 1 Home Mortgage Disclosure Act (HMDA) 12 CFR 1003 Purpose: Detect illegal discrimination Detect predatory lending
What America Is Thinking On Energy Issues February 2016
What America Is Thinking On Energy Issues February 2016 South Carolina Presented by: Harris Poll Interviewing: January 22-31, 2016 Respondents: 600 Registered Voters Method: Telephone Weighting: Results