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

Supplemental Hiv Prophylaxis Reimbursement Request Form - Ohio Attorney General Sexual Assault Forensic Examination (Safe) Program is a legal document that was released by the Ohio Attorney General - a government authority operating within Ohio.

Form Details:

  • The latest edition currently provided by the Ohio Attorney General;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Attorney General.

ADVERTISEMENT
ADVERTISEMENT

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

1341 times
Rate (4.3 / 5) 94 votes
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