Attachment J-2 Billing Authorization.pdf
PDF 210 KB Posted
- Attached to
- Residential Drug Treatment Services
- Solicitation number
- 9594CS26Q0055
About this file
This is a Billing Authorization memorandum 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, scheduled for admission on 11/6/05 with discharge no later than 12/4/06. The pick-up location and time are specified as 601 Indiana at 10:00 am, with a maximum obligation/invoice amount of $100.00.
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. The confirmation form must indicate whether the patient was admitted and, if not admitted, provide reasons for non-admission. The memorandum is routed through the Program Analyst (Contracting Officer's Representative) and includes a response template for the vendor to confirm treatment status. All communications regarding admission confirmation or non-admission must be submitted to the Treatment Referral Coordinator at the specified email address.
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Text version
Attachment No. 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 emailed to the Treatment
Referral Coordinator at rpt@csosa.gov.
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 email this form back to me at rpt@csosa.gov to indicate reasons for non-admission.
Thank you.
Email to rpt@csosa.gov
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 .