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Invoice Number: Invoice Date: This form is for IRIS-funded non

Invoice Number: Invoice Date: This form is for IRIS-funded non 2025

Invoice Number: Invoice Date: This form is for IRIS-funded non Preview on Page 1

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The document is an invoice form for IRIS-funded non-HIPAA claims, detailing the necessary information required for billing Medicaid services. It includes sections for participant and provider details, billing period dates, service descriptions, and compliance agreements with Medicaid policies. The form emphasizes the importance of adhering to regulations regarding service provision, payment acceptance, record-keeping, and confidentiality.

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