10/18/2000 Agreement
. Agency for Health Care Administration
Electronic Oaims Submission Agreement
This form must be completed by any provider who plans to submit claims
electronically for reimbursement by Florida Medicaid.
I, MOil roe. Crh I (\ ~t:. ~':.sented by
(Provider Name)
S h ,e r I, y ,c,. 4L c... ...... '" "
(Repres.6ttative's Name)
understand and agree to the following:
2.
Payment of claims will be from federal and state funds and that any falsification or concealment of
material fact may be prosecuted under Federal and State laws.
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Providers must safeguard the Medicaid program against abuse in the use of electronic c~s ~ ~
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Providers must correctly enter the claims data, monitor the data and certify that the dat~fed is......
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Providers must assure that the transmission of claims data is restricted to authorized pefti#'-n~ to c.:i
prevent erroneous payments by the Agency's fiscal agent that might result from carele~nesMr f~..
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5. Providers must have on file the applicable source data to substantiate the claim submitted to the
Medicaid program.
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6. Providers must allow the Agency or any of its designees and representatives of the office of the
Auditor General or the Attorney General to review and copy all records, including source documents
and data related to information entered through electronic claims submission.
7. Providers must abide by all Federal and State statutes, rules, regulations, and manuals governing the
Florida Medicaid program.
8. Providers must sign and adhere to all conditions of the Medicaid Provider Agreement and be officially
enrolled in the Medicaid program to participate in electronic claims submission.
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(Date)
Mailing Address~_O j~)O')( O~O\ \
BY:
Provider ID Number: 08 D 3 ,,\ - 00
Telephone # used for
Making and Receiving Calls: ~OO -'4 '1- d.. , b 5
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Telephone # used for
Claims Submission: Boo - 4 \ 1- d.. \ b S
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(Florida Medicaid Program - Do not write below this line)
Received By
Title
~TTeST: DANNY l. kOLHAGE, aERK
8~~' le. tl2v )J~
DEPUTY CLERK
Date
Revised March 1999