Hhsc form 1595 billling resolution request: Fill out & sign online

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Click ‘Get Form’ to open the hhsc form 1595 in the editor.
Begin by entering the Contractor Name and Contract Number at the top of the form. This information is essential for identifying your billing request.
Fill in the Date, Contractor Contact Name, and their Telephone Number. Ensure that all contact details are accurate for effective communication.
Provide the Contractor Contact's Mailing Address and Fax Number. This will facilitate any necessary correspondence regarding your request.
Next, enter the Individual's No. and the Name of the Individual Receiving Services. Include their Service Group and Service Code to specify what services were provided.
Indicate the Service Dates by filling in both 'From' and 'To' fields, along with Units and Amount related to those services.
Add any relevant comments in the designated section to clarify your request further.
Finally, ensure that a Contractor Representative signs and dates the form before submitting it along with all supporting documentation.

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