[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287913-105":53,"doc-detail-287913-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","signature-transmittal-form-for-paper-invoices","Signature Transmittal Form for Paper Invoices","","This document is an official Signature Transmittal Form for the Pennsylvania Department of Human Services, Office of Medical Assistance Programs. It serves as a formal submission cover sheet for providers and service bureaus submitting paper invoices. The form requires the entry of the number of invoices, service bureau identification, PROMISeTM provider numbers, and corresponding NPI numbers. By signing, the submitter certifies the accuracy and completeness of the enclosed claims, acknowledging the legal implications regarding federal and state funding, specifically concerning false claims or concealment of material facts. It is mandated that users photocopy the completed form for their own records. This ensures compliance with state administrative standards for healthcare billing and 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is the purpose of the Signature Transmittal Form?","Question",{"text":108,"@type":109},"It is used by Service Bureaus or Providers to formally submit paper invoices to the Pennsylvania Department of Human Services Office of Medical Assistance Programs.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What specific identifiers are required for each invoice submission?",{"text":113,"@type":109},"Submitters must provide the PROMISeTM provider number and the corresponding NPI number for each record included in the submission.",{"name":115,"@type":106,"acceptedAnswer":116},"What does the signature on this form certify?",{"text":117,"@type":109},"The signature certifies that the information on the enclosed invoices is accurate and complete, and acknowledges that the submitter understands the legal consequences of submitting false claims or concealing material facts regarding federal and state funds.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287913,1790096792,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},137455077381,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","SIGNATURE TRANSMITTAL FORM  \nFOR PAPER INVOICES  \nJULIAN DATE RECEIVED  \nLEAVE THIS AREA BLANK  \nI am hereby submitting the enclosed invoices as an approved Service Bureau or Provider.  \nNUMBER OF INVOICES  \nSERVICE BUREAU NUMBER  \n\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n| --- | --- |\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n| PROMISeTM PROVIDER NUMBER | NPI NUMBER |\n\nIMPORTANT: PLEASE PHOTOCOPY FORM FOR YOUR FILE COPY  \nI certify that the information on the enclosed invoices is accurate and complete as submitted.  \nI 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.  \nPRINT CONTACT NAME AND PHONE NUMBER SIGNATURE OF SERVICE BUREAU/PROVIDER DATE  \nOR DESIGNEE","cbCaitgvvZyIp50f","https://ap.wps.com/l/cbCaitgvvZyIp50f","pdf",84506,"English","# Submission Details\n## Provider and Billing Information\n## Certification and Signature","[{\"question\":\"What is the purpose of the Signature Transmittal Form?\",\"answer\":\"It is used by Service Bureaus or Providers to formally submit paper invoices to the Pennsylvania Department of Human Services Office of Medical Assistance Programs.\"},{\"question\":\"What specific identifiers are required for each invoice submission?\",\"answer\":\"Submitters must provide the PROMISeTM provider number and the corresponding NPI number for each record included in the submission.\"},{\"question\":\"What does the signature on this form certify?\",\"answer\":\"The signature certifies that the information on the enclosed invoices is accurate and complete, and acknowledges that the submitter understands the legal consequences of submitting false claims or concealing material facts regarding federal and state funds.\"}]","Signature Transmittal Form for Paper Invoices | PDF",1789632877]