Attachment J-7 Vendor Referral Letter (Billing Authorization).docx
DOCX document 22 KB Posted
- Attached to
- Supportive Housing Services (Up to 180 Days)
- Solicitation number
- 9594CS26Q0075
About this file
This is a Vendor Referral Letter template establishing billing authorization procedures for supportive housing services contractors working with the Court Services and Offender Supervision Agency (CSOSA). The document serves as a standard authorization form that vendors must complete to enable CSOSA to process billing and payment for services rendered under the Supportive Housing Services contract (Solicitation 9594CS26Q0075).
The template outlines the framework for vendors to formally authorize billing procedures, establishing the contractual mechanism for compensation related to up to 180 days of supportive housing services. This form is one of multiple required attachments within the solicitation package and represents an administrative requirement that prospective contractors must address as part of their proposal submission and contract performance obligations with CSOSA.
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Text version
Attachment J-7
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
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