31. SIGNATURE OF The provider or designated authorized individual must PHYSICIAN OR SUPPLIER sign and date the claim certifying that the services INCLUDING DEGREES OR were personally rendered by the provider or under CREDENTIALS the provider’s direction. signature” is “Provider’s defined as the provider’s actual signature, a rubber stamp of the provider’s signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. 32. SERVICE FACILITY If other than home or office, enter the name and LOCATION INFORMATION street, city, state and zip code of the facility where services were performed. a. Not required. b. Not required. 33. BILLING PROVIDER INFO Billing provider’s name and complete address. & PH # Telephone number is requested but not required. a. (blank) Enter NPI of the billing provider or b. Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. 292.400 Special Billing Procedures Not applicable to this program.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider’s direction. “Provider’s signature” is defined as the provider’s actual signature, a rubber stamp of the provider’s signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. 32. SERVICE FACILITY LOCATION INFORMATION If other than home or office, enter the name and street, city, state and zip code of the facility where services were performed. a. Not required. b. Not required. 33. BILLING PROVIDER INFO & PH # Billing provider’s name and complete address. Telephone number is requested but not required. a. (blank) Enter NPI of the billing provider or b. Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. 292.400 Special Billing Procedures Not applicable to this program.
TRANSP_II.docx