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CSSNEWPORTALBILLING FORMRev062411 doc

CSSNEWPORTALBILLING FORMRev062411 doc 2026

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The document is a billing form for Consolidated Supports and Services (CSS) provided to non-waiver individuals. It includes sections for agency information, service details, individual names, and payment amounts. The form requires certification of compliance with federal civil rights laws and mandates record-keeping for six years. Claims submitted more than two years after the service date must include an explanation letter. Completed forms are to be sent to the New York State Office for People with Developmental Disabilities.

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Click ‘Get Form’ to open the CSSNEWPORTALBILLING FORMRev062411 in the editor.
Begin by entering the AGENCY NAME and FEDERAL EMPLOYER ID # at the top of the form. This information is crucial for identification and processing.
Fill in the DDSO and CONTACT PERSON fields, along with their PHONE #. Ensure accuracy as this will facilitate communication regarding your submission.
Specify the MONTH / YEAR OF SERVICE. This helps in tracking and validating claims based on service dates.
List each INDIVIDUAL NAME along with their respective TABS ID, Hr.UNITS, AMOUNT PAYABLE, and FEE in the designated sections. Be thorough to avoid delays in processing.
Calculate and enter TOTALS FOR PAGE at the bottom of the section to summarize your billing amounts.
Complete the PAYEE CERTIFICATION section by signing, adding your TITLE, and DATE. This certifies that all provided information is accurate and compliant with regulations.
Finally, attach any required forms to a completed STANDARD VOUCHER (AC92) before forwarding it to the specified address for processing.

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