Attachment J-1 Vendor Referral Letter-Billing Authorization.pdf

This document is a Vendor Referral Letter and Billing Authorization memorandum from a Referral Placement Coordinator to a Treatment Vendor through a Program Analyst, COR. The memorandum authorizes treatment services for a patient identified as John Doe (PDID = 123456) with a maximum treatment duration of 28 days. The authorized obligation and invoice amount shall not exceed $100.00. The patient is scheduled for pick-up at 601 Indiana at 10:00 am on 11/6/05, with a discharge date not to exceed 12/4/06. The treatment vendor is required to complete and return an admission confirmation form within 24 hours of the scheduled admission date via email to rpt@csosa.gov, or provide written reasons for non-admission if the patient cannot be admitted.

The document includes a response template for the treatment vendor to complete and return to the Referral Placement Coordinator. The vendor must confirm whether the patient was admitted and provide the treatment vendor name, patient identifiers, treatment duration, and admission status. This authorization serves as billing authorization for the treatment services rendered, with all communications and confirmations directed to the Treatment Referral Coordinator at the specified email address.