AUTHORIZATION TO PURCHASE OF SERVICE AND PROVIDER OF CARE CLAIM FORMS
Please process the Authorization to Purchase of Service and Provider of Care Claim forms within the appropriate time frame. The properly completed and signed claim should reach us by the 3rd working day of the month for our first payment on the 11th and by the 15th working day of the month for our second payment on the 21st day of the month. Although we make every attempt to meet these dates, there may be a delay of up to 3 working days.
PAYMENTS FOR RESPITE SERVICE FAMILY MEMBER
PAYMENTS FOR BEHAVIORAL SERVICES
Please complete the DS5862 form (English DS5862, Spanish DS5862, Chinese DS5862, Vietnamese DS5862, Tagalog DS5862) and submit by email attachment or fax to the respective Fiscal Service Representative.
PAYMENTS FOR BEHAVIORAL SERVICES CO-PAY
Please submit the Explanation Of Benefit (EOB) form by email attachment or fax to the respective Fiscal Service Representative.