"Supplemental Hiv Prophylaxis Reimbursement Request Form - Ohio Attorney General Sexual Assault Forensic Examination (Safe) Program" - Ohio

This fillable "Supplemental Hiv Prophylaxis Reimbursement Request Form - Ohio Attorney General Sexual Assault Forensic Examination (Safe) Program" is a document issued by the Ohio Attorney General specifically for Ohio residents.

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Download "Supplemental Hiv Prophylaxis Reimbursement Request Form - Ohio Attorney General Sexual Assault Forensic Examination (Safe) Program" - Ohio

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SUPPLEMENTAL HIV PROPHYLAXIS REIMBURSEMENT REQUEST FORM
Ohio Attorney General Sexual Assault Forensic Examination (SAFE) Program
PLEASE ANSWER ALL QUESTIONS
1. Medical Facility:
2. SAFE Account (Vendor ID No.):
3. Patient Name:
4.Treatment Date for Reimbursement:
5. Patient Medical Record Number:
//
Services provided on this date (note all services for
reimbursement reflected on the attached invoice):
6. First Treatment Date:
//
What are the total costs requested this billing cycle for
the HIV Prophylaxis protocol?
___________________________
7.
Along with the submission of the Reimbursement Request Form, attach a pdf itemized statement reflecting actual costs
of medications and services rendered (See instructions).
By sending this electronic transmission, I solemnly affirm that I am duly authorized to make this submission on behalf of
the above noted medical facility, and that all information included herein is true and accurate to the best of my knowledge
and belief.
Submit To:
For Questions about Billing, Please Call:
safe@ohioattorneygeneral.gov
(614) 466-4797
SUPPLEMENTAL HIV PROPHYLAXIS REIMBURSEMENT REQUEST FORM
Ohio Attorney General Sexual Assault Forensic Examination (SAFE) Program
PLEASE ANSWER ALL QUESTIONS
1. Medical Facility:
2. SAFE Account (Vendor ID No.):
3. Patient Name:
4.Treatment Date for Reimbursement:
5. Patient Medical Record Number:
//
Services provided on this date (note all services for
reimbursement reflected on the attached invoice):
6. First Treatment Date:
//
What are the total costs requested this billing cycle for
the HIV Prophylaxis protocol?
___________________________
7.
Along with the submission of the Reimbursement Request Form, attach a pdf itemized statement reflecting actual costs
of medications and services rendered (See instructions).
By sending this electronic transmission, I solemnly affirm that I am duly authorized to make this submission on behalf of
the above noted medical facility, and that all information included herein is true and accurate to the best of my knowledge
and belief.
Submit To:
For Questions about Billing, Please Call:
safe@ohioattorneygeneral.gov
(614) 466-4797
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