Signature Transmittal For Paper Invoices {MA 307} | Pdf Fpdf Doc Docx | Pennsylvania

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Signature Transmittal For Paper Invoices {MA 307} | Pdf Fpdf Doc Docx | Pennsylvania

Last updated: 1/4/2017

Signature Transmittal For Paper Invoices {MA 307}

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Description

JULIAN DATE RECEIVED SIGNATURE TRANSMITTAL FORM FOR PAPER INVOICES LEAVE THIS AREA BLANK I am hereby submitting the enclosed invoices as an approved Service Bureau or Provider. NUMBER OF INVOICES SERVICE BUREAU NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER PROMISeTM PROVIDER NUMBER NPI NUMBER IMPORTANT: PLEASE PHOTOCOPY FORM FOR YOUR FILE COPY I certify that the information on the enclosed invoices is accurate and complete as submitted. I understand that payment and satisfaction of these claims will be from federal and state funds and that I may be prosecuted for false claims, statements or documents, or concealment of material facts. PRINT CONTACT NAME AND PHONE NUMBER SIGNATURE OF SERVICE BUREAU/PROVIDER OR DESIGNEE DATE American LegalNet, Inc. www.FormsWorkFlow.com MA 307 2/15

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