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- Click ‘Get Form’ to open the ddsn fsp form in the editor.
- Begin by entering the Provider # and Provider Name at the top of the form. This information is essential for identifying your service provider.
- Fill in the Consumer's name, SSN#, and Medicaid #. Ensure accuracy as this data is crucial for billing purposes.
- Specify the Date Range for services provided by entering start and end dates in the designated fields.
- In Section A, indicate the units of service for EIBI Annual Assessment and Plan Development & Training. Enter rates and total amounts due accordingly.
- For Sections B and C, record weekly hours for EIBI Line Therapy and Lead Therapy respectively. Make sure to adhere to maximum hour limits per week.
- Complete Section D by documenting dates and total hours for EIBI Plan implementation, ensuring you stay within monthly limits.
- Finally, certify your entries by signing and dating at the bottom of the form before submission.
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| 2011 | 4.8 Satisfied (102 Votes) |
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