Fillable hfs 2212 form-2026

1. Click ‘Get Form’ to open the fillable HFS 2212 form in the editor.
2. Begin by entering the Provider Name exactly as it appears on your Provider Information Sheet. Ensure you use capital letters for clarity.
3. Input the Provider Number without any punctuation or spaces, following the same format as shown on your Provider Information Sheet.
4. Fill in the Billing Date using MMDDYY format. For example, January 1, 2001 should be entered as 010101.
5. Complete at least one of the service sections by entering the Recipient Name and Recipient Number accurately, ensuring no punctuation is used.
6. For each item billed, provide a Diagnosis Description and corresponding Diagnosis Code from the ICD-9-CM manual, ensuring all entries are precise.
7. Review all fields for accuracy before signing. The signature must be handwritten in black or dark blue ink; stamped signatures are not acceptable.

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