Attachment J-2 Billing Authorization.pdf
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- Solicitation number
- 9594CS26Q0004
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Summary of Attachment J-2: Billing Authorization
This is a Billing Authorization memorandum (Contract 9594CS26Q0004) from the Referral Placement Coordinator to a Treatment Vendor authorizing treatment services for a patient. The document authorizes treatment for John Doe (PDID 123456) with a maximum duration of 28 days and a financial obligation not to exceed $100.00. The patient is to be picked up at 601 Indiana at 10:00 am on the admission date of 11/6/05, with discharge no later than 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 fax to (202) 220-5463. The fax response form must indicate whether the patient was admitted and, if not admitted, provide the reason for non-admission. The vendor must include patient name, PDID number, treatment type, duration, pick-up location and time, and admission status on the return fax. All communications are to be directed through the Program Analyst serving as Contracting Officer's Representative (COR).
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Text version
9594CS26Q0004
Attachment J-2: Billing Authorization
MEMORANDUM
To: Treatment Vendor
Through: Program Analyst, COR
From: Referral Placement Coordinator
Date: _______________________
Subject: Billing Authorization
Enclosed please find a referral package for John Doe (PDID = 123456) who is in need of treatment. The duration of treatment for this Patient shall not exceed 28 days.
You are required to complete the attached admission confirmation from within 24 hours of the scheduled admission date. The admission confirmation must be faxed to Treatment Referral Coordinator on (202) 220-5463.
Name PDID Number
Admission Date
Discharge Date Shall Not Exceed
Pick-Up Location/Time
Obligation/Invoice Shall Not Exceed
John Doe 123456 11/6/05 12/4/06 601 Indiana 10:00 am
$100.00
No later than 24 hours after the scheduled pick-up, please fax this form back to me on (202) 220- 5463 to indicate reasons for non-admission.
Thank you.
FAX
To: Referral Placement Coordinator
From: Treatment Vendor
Date: _____________________________________________
Name PDID Number
Vendor Treatment Status – Admitted? Yes or No If no, indicate reason
John Doe 123456 Your organization
30 days 601 Indiana 10:00 am
File details come from the government source that posted it. Updated .