LTC-19, Request for Billing Assistance
|New Jersey Department of Human Services |
|Division of Aging Services |
|Office of Community Choice Options |
| Northern Regional | Southern Regional |
|Community Choice Options Field Office |Community Choice Options Field Office |
|Telephone: (732) 777-4650 |Telephone: (609) 704-6050 |
|Fax: (732) 777-4681 |Fax: (609) 704-6055 |
|REQUEST FOR BILLING ASSISTANCE |
|Facility Name |Provider Number |
| | |
|Facility Contact Person |Telephone Number |Fax Number |
| | | |
|Client Name (Last) (First) (MI) |
| |
|Social Security Number |Medicaid Number |
| | |
|Date of Birth |Sex |Edit/Error Code(s) |
| |Male Female | |
|Date of Admission |Date of PAS | |
| | | |
|Denied Dates of Service |Date LTC-2 Submitted (Attach proof of LTCFO Referral) |
| | |
|Provider Explanation, if necessary: |
| |
|FOR LONG TERM CARE FIELD OFFICE USE ONLY |
|Action Taken/Explanation: |
| |
|Date Corrected: |
| |
|Correction Could Not be Made (Explanation): |
| |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- request for hearing student
- request for hearing student loan
- request for hearing department of educat
- request for hearing student loan garnishment
- request for hearing department of education
- request for hearing student loan garnish
- request for proposal template microsoft word
- ssa request for hearing form
- awg request for hearing
- dental codes for billing and insurance
- v codes for billing eyeglasses
- keratoconus codes for billing insurance