07/17/2002 Agreement
Clerk of lIIe
Circol coon
Danny L. Kolhage
Clerk ofthe Circuit Court
Phone: (305) 292-3550
FAX: (305) 295-3663
e-mail: phancock@monroe-clerk.com
Memnrandum
TO: Louis Latorre, Director
Social Services Division
ATTN: Dee Simpson
In-Home Services Program
FROM: Pamela G. Han('~
Deputy Clerk D
DATE: August I, 2002
At the July 17, 2002, Board of County Commissioner's meeting the Board granted approval
and authorized execution of Electronic Remittance Voucher Agreement between Monroe County and the
Agency for Health Care Administration Florida Medicaid that will allow Monroe County to receive claim
remittance vouchers electronically for EMS, Transportation, In.Home Services, Bayshore Manor, Assisted
Care Services and the Nutrition programs.
Enclosed are four duplicate originals for your handling. Should you have any questions
please do not hesitate to contact this office.
Cc: County Administrator w/o document
County Attorney
Finance
File '"
From: EDI suppon Unit To: Salvotone
Dale: 6/12/02 Tim~~ H~AM
Page 3 of 3
. .
. \~I~~*C)~~q:~,B~~J~,h'~~~illlgilj:~$i~ijR~:,:, ,'.,
:l~J~!rilij i~ iB~ml~@,p~~~.~!M~fili~~~~~!~j:! [:i..,
-
Any provider planning to re(~eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messages when you receive payment information. '.
This AGREEMENT made and entered into this 17th day d July , ~~, by and
between the Agency for Health C U<~ Administration, hereinafter called the "Agency," acting in its
own right as the Agency responsihle for administrating the Medical Assistance Program (Title XIX),
and by In-Home Services , hereinafter called "Provider."
WITNESSETH:
In consideration of the mutual pre mises and covenants containe i herein and other good and valuable
consid~ration, t.he parties heret.o agr~e as follows:
The Agency shall allow the Provi ier to receive remittance Vou( hers through Internet download from
the fiscal agent's Internet web site. Please check who will be receiving your remittance vouchers.
J,..,..
,1,-,
a. ~ YOllrselforComp~ny
b. _ Billing Agent (Ve Idor)
_.. "'-:l
-"'~ C:J,
o C:, '"C::l
Z 1:>> ''-J
(Vendor'! ~ t-
('TJ -',," _: l"J
0:""".: I
(Vendor's Pro~ber)
...... 0
~n!:: ~ Xl
Date :B7 17.~:j ~ i
L)
APPROVED AS TO FORM
AND LE L SUFFICI
"
r-
rn.
o
"
o
::0
Vmdor's Name)
Provlder/Representative Signatl r McCoy
(Notilrized siglla/ure required)
ProvIder number 0249211 00
ProvIder Address 1100 Simonton st. Rm 1-197
Key West FI 33040
(Florida Medicaid Program - Do nol wrltf below this line)
Date Received
Received By
FMMIS Update
Title
ECS Spec
Date
~........:. .... ........_ .11111... .. , '.-'-' ....
r'c:t~C_UIJ
Insl:ructionllnformation Sheet
Electronic Remittance Voucher Agreement - Florida Medicaid
ERV Agreements
. Fill out an original copy of t~e attached ERV Agreement fer each Florida Medica'd Provider
number you are requestirg for Electronic Remittance Vou(:her reports via the Int9met.
. Each Agreement must halle a notarized signature before i: can be processed. Leave the
bottom section blank (for =Iorida Medicaid Program ONLY). If this section is missing, please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via -tape', you will no longer receive
these tapes. The tape a lei ERV (Internet) format ara NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thE! original, notarized ERV
Agreement(s) via mail to:
ACS/Consultec
A TTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee. FL 32308
Contact Information
'..
Contact Name Sal
Contact Tel # 305-
E.Mail szap
Jrovider'.s Office
'::::::':VefidorISmilig: Agent'
;g~~!~~;V whqwitt~~r~vinp; or
:QQWhlO'ading your,ERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
From: EDI suppon Unlt To: Salvolone
Dale: 6/12/02 Time: 11:14:32AM
Page 3 of 3
, - ",' ,,"'" ',,',,' ,
',', -:;Agencrfo,rlleaIthCare AdndijJstration ,
.[~.~~ron ic jle~.i.!t~p~~:,VQti.~~.}t.~~~~~~!l~;
-
:;:':'::;;'''-'; .".
""...V_'>"'.":"".
,,,,:.:;
Any provider planning to rel:eive claim remittance vouchers electronically must
complete this form. If you ~ign this agreement, you will not receive remittance
voucher (RV) banner messag:es when you receive payment information. '
This AGREEMENT made and entered into this q.et. day d G-4, , z.o ..~, by and
between the Agency for Health Clr'~ Administration, hereinafter c~ency," acting in its
own right as the Agency responsihk for administrating the Medical Assistance Program (Title XIX),
and by Nlltri t- inn __, hereinafter called "Provider."
WITNESSETH:
In consideration of the mutual pre mises and covenants cont-aine i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi Jcr to receive remittance voue hers through Internet download from
the fiscal agent's Internet web site. Please check who will be re( eiving your remittance vouchers.
a. ~ YourselforComp'lOY
b. _ Billing Agent (Ve Idor)
Vmdor's Name)
(Vendor'! Address)
(Vendor's Provider Nwnber)
McCoy
'87 '1 h....
Date
ProVider Address 1100 Simonton st. Rm 1-201
Key West, FL 33040
(Florida Medicaid Program - Do not writ.. below this line)
Received By
Date Received
FMMIS Update
Title
ECS Spec
Date
rd~C; _ VI ..)
Instruction/Information Sheet
Electronic Reml ttance Voucher Agreeme Ilt - Florida Medicaid
ERV Agreements
. Fill out an original copy of tre attached ERV Agreement fer each Florida Medica,d Provider
number you are requestirg for Electronic Remittance Vouc:her reports via the Internet.
. Each Agreement must halle a notarized signature before i can be processed, Leave the
bottom section blank (for =Iorida Medicaid Program ONLY). If this section is mi::sing, please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via "tape', you will no longer receive
these tapes. The tape a lei ERV (Internet) fonnat are NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatio1 Sheet, and return with thE~ original, notarized ERV
Agreement(s) via mail to:
ACS/Consultec
ATTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee, FL 32308
Contact Information
..
Contact Name Sal
Contact Tel # 305-
E-Mail szap
;':::Vendor/Billing::Agent
:9~llf:P~r1Y who wiHR~ r~ving or
downloading YQurERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
From: EDI Support Unit To: Salvotone
Date: 6/12102 Time: 11:14:32AM
Page 3 of 3
, '
0."""_- ___ ,_,._._... . ....." d.'"..._ _ ......_ ..._.._... ",......., ......_. "._'.'....0
. Agenc)' for lI~alth, Care ~:~ln~#~:strati~n
,l~l~~r.on ic~~m~,~~,pC~V:9u~~nr~~g~~~~!tf
-
-
.-,:;
Any provider planning to re(:eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messag:es when you receive payment information.'
This AGREEMENT made and entered into this 17~ day <of ~, _ Lo,. Z,by and
between the Agency for Health Clf'~ Administration, hereinaftel' c~ency," acting in its
own right as the Agency responsihle for administrating the Medical Assistance Program (Title XIX),
and by Assis.t.ed Care _, hereinafter called "Prcvider."
Services
WITNESSETH:
In consideration of the mutual pre mlses and covenants containe i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi:kr to receive remittance voue hers through Internet download from
the fiscal agent's Internet web site, Please check who will he receiving your remittance vouchers.
a. ~ YourselforComplny
b. _ Billing Agent (Vcldor)
(Vendor'~ Address)
(Vendor's Provider Number)
McCoy Date
140159900
5200 College Rd.
Key West, Fl 33040
(Florida Medicaid Program - Do not write below this line)
Date Received
Received By
FMMIS Update
Title
ECSSpec
Date
-....... "'" _''-_ "'''l. " , , ....- . ....
,-aye _ '-" -.J
, '
Instructionllnformation Sheet
Electronic Remittance Voucher Agreement - Florida Medicaid
ERV Agreements
Fill out an original copy of t~e attached ERV Agreement fer each Florida Medica,d Provider
number you are requestirg for Electronic Remittance Vouc:her reports via the Internet.
. Each Agreement must hav'e a notarized signature before i, can be processed, Leave the
bottom section blank (for =Iorida Medicaid Program ONL Yl. If this section is missing, please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via "tape'. you will no longer receive
these tapes. The tape a lei ERV (Internet) format are NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thE! original, notarized ERV
Agreemellt(s) via mail to:
ACS/Consultec
ATTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee, FL 32308
Contact Information
Contact Name Sal
Contact Tel #
305-
E.Mail szap
:Vel1dor/BiUilig: Agent'
:P~$':P.~rty who witl~( r~vinR or
downloading YQurERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
t-rom: EDI suppon Unit To: Salvolone
Dale: 6/12102 TIme: 11:14:32 AM
Page 3 of 3
~ '
~JlA11'1r.~~td1llt&i..........
-
Any provider planning to re(:eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messages when you receive payment information.'
This AGREEMENT made and entered into this 17.d, day eo[ G.4 , z..~, by and
between the Agency for Health C u'~ Administration, hereinafteJ' c~ency:' acting in its
own right as the Agency responsible for administrating the Medical Assistance Program (Title XIX),
and by Bayshore Manor , hereinafter called "Provider."
WITNESSETH:
In consideration of the mutual pre mises and covenants containe 1 herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi 1er to receive remittance VOlle hers through Internet download from
the fiscal agent's Internet web site. Please check who will he re<eiving your remittance vouchers.
a. ~ YourselforComplny
b. _ Billing Agent (Ve Idol')
Vmdor's Name)
(Vendor\ Address)
'PrpViper/RepresentatI Sig
. ", ",J
, .J'foPfized sigllature reqlliT<
I " ~ I
_~,:'j.",~;':,:~,,_;,{!:,;.'/l ___~(I
" 'ProVider number 676448700
(Vendor's Provider Number)
McCoy
~ 172-.~
r
Date
APPROVED AS TO aRM
AND l SUFF
ProVider Address 5200 College Rd.
Key West, FL 33040
(Florida Medicaid Program - 00 not write below this line)
Date Received
Received By
FMMIS Update
Title
ECS Spec
Date
/<
--.....-.;. ... ,_....._ I II I U.. .. " . . "'-' ...,
'elye _ UI .)
, .
Instructionllnformation Sheet
Electronic Reml tttlnce Voucher Agreeme rJt - Florida Medicaid
ERV Agreements
. Fill out an original copy of tt.. e attached ERV Agreement fer each Florida Medica,d Provider
number you are requestirg for Electronic Remittance Vouc:her reports via the Int3rnet.
. Each Agreement must halle a notarized signature before i can be processed, Leave the
bottom section blank (for =Iorida Medicaid Program ONLY). If this section is missing, please
contact us at 1-8oo-829-C218, for a complete copy..
NOTE: If you are currently receiving RV's via -tape' I you will no longer receive
these tapes. The tape a lei ERV (Internet) format ara NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thEe! original, notarized ERV
Agreement(s} via mail to:
ACS/Consultec
A TTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee, Fl32308
Contact Information
:::'
,
Contact Name Sal
Contact Tel # 305-
E-Mail szap
~rovider',s Offi~
::::::'Vendor/BiHlng::Agent '
~g~~:!)~y wh()\Vjll~(r~viIi~or
dOWnloading yourERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
From: EDI Support Unit To Salvotone
Date: 6/12102 Time: 11: 14:32 AM
Page 3 of 3
&;
Agency for Health Care A(hni~~stration
Electron icRemltt~~ce V ()u~6ur:AgreeIIl,.~~t
II!
Any provider planning to re(~eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messag;es when you receive payment information. .
This AGREEMENT made and entered into this 17,d, day c.f ~ ,'Zoo~, by and
between the Agency for Health C lr,~ Administration, hereinafteJ' c th "Agency," acting in its
own right as the Agency responsible for administrating the Medical Assistance Program (Title XIX),
and by Transportation __, hereinafter called "Prcvider."
WITNESSETH:
In consideration of the mutual pre mlses and covenants containe i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi 1cr to receive remittance voue hers through Internet download from
the fiscal agent's Internet web site, Please check who will be re( eiving your remittance vouchers.
a. ~ YourselforCompluy
b. _ Billing Agent (Ve Idol')
(Vendor'! Address)
(Vendor's Provider Number)
AN71;;~N
'()~
--- ---
ProV\lder/Representative Signatl r<: Ch r les McCoy Date
\,. "
(IYilttr,rized siglla/ure required) Ma or
Pf()X'lder num~r 0881 511 00
Provider Address 1100 Simonton st. Rm 1-181
Key West, FL 33040
(Florida Medicaid Program - Do nof writt below this line)
Date Received
Received By
FMMIS Update
Title
ECS Spec
Date
__...,..... "" .....,..... _ I""\' .. . I ...._ . ~..
r.~yc _ v> J
Inst:ructionllnformation Sheet
Electronic Reml ttance Voucher Agreeme,..,t - Florida Medicaid
ERV Agreements
Fill out an original copy of t~e attached ERV Agreement fer each Florida Medicaid Provider
number you are requestirg for Electronic Remittance Vou<;her reports via the Int3rnet.
. Each Agreement must haole a notarized signature before i. can be processed. Leave the
bottom section blank (for ::Iorida Medicaid Program ONL Yl. If this section is missing, please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via "tape', you will no longer receive
these tapes. The tape a lei ERV (Internet) fonnat ar3 NOT the same database
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thE! original, notarized ERV
Agreement(s) via mail to:
ACS/Consultec
A TTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee. FL 32308
Contact Information
,.,
Contact Name Sal
Contact Tel #
305-
E-Mail szap
':::Vehdor/BiUiiig'. Agent
:9~m-.P.;l.rty who wiltR~ .r~vinR or
downloading yourERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
From: EDt Support Unit To: Salvolone
Dale: 6/12/02 TimE: 11:14:32 AM
Page 3 of 3
.., ," ,
, Agency for lIealth Care ~:4n~~~,~stration ,
~;Electron ic ll~lnltt~Jlce V():tl~~nri:~~~~e..t . '
-
Any provider planning to rel:eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messag:es when you receive payment information. '
This AGREEMENT made and entered into this /7.8, day <of G4 ,~o't-, by and
between the Agency for Health Clf<~ Administration, hereinaftel' c~ency," actingin its
own right as the Agency responsible for administrating the Medical Assistance Program (Title XIX),
and by EM~ _, hereinafter called "Prcvider."
WITNESSETH:
In consideration of the mutual pre ffilses and covenants containe i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi icr to receive remittance voue hers through Internet download from
the fiscal agent's Internet web site, Please check who will be re( eiving your remittance vouchers.
a. ~ Yourself or Compln y
b. _ Billing Agent (Ve Idor)
J~:':>0'
\."". ~," '\~~~'\~
,J'~~R~~er/Representative Signall r€ Charles McCoy Date
~,:;,\.:~f!t~rzed siglla/llre required) Mayor
;1 ',': ""'('. /1
'i'f.roifder number 0877361 00
>.,
(Vendor'! Address)
Telephone Nwnber)
(Vendor's Provider Nwnber)
BY ~NNE V~~ftk
DATE ~,
ProVider Address 4QO fi1rn!=;t- !=;tP- 170
Marathon, FL 33050
(Florida Medicaid Program - Do not writ" below this line)
Date Received
Received By
FMMIS Update
Title
ECS Spec
Date
............. ...... _......_ "".l. .. , . -'- . ....
(aye _ v' J
Instruction/Information Sheet
Electronic Reml ttance Voucher Agreeme '1t - Florida Medicaid
ERV Agreements
. Fill out an original copy of tre attached ERV Agreement fer each Florida Medica.d Provider
number you are requestirg for Electronic Remittance Vou<;her reports via the Internet.
. Each Agreement must haole a notarized signature before i can be processed, Leave the
bottom section blank (for =Iorida Medicaid Program ONLY). If this section is missing, please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via "tape', you will no longer receive
these tapes. The tape a lei ERV (Internet) format ar3 NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up,
Information Sheet
Complete this Informatiol Sheet, and return with thE~ original. notarized ERV
Agreement(s) via mail to:
ACS/Consultec
ATTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee. FL 32308
Contact Information
I: ..
Contact Name Sal
Contact Tel # 305-
E-Mail szap
':::::.'.Vendor/Bimrig: Agent
:Qth,", ,.~,:.,'"'..,,:pa,, ',I1:y whq willb. ( r~.:,..,.:, .,,'vinp; or
:dOWh16ading YQtirBRVReports)
Zappulla
295-3649
pulla@monroe-cle k.com