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Only established clients should submit billing using this form.
For information about becoming a Primary Solutions client, please
click here.
If you were directed by your county board to submit
local billing
online, please go to
www.OhioDD.com
.
* Vendor:
* County:
Adams
Allen
Ashland
Ashtabula
Athens
Auglaize
Belmont
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Jefferson
Knox
Lake
Lawrence
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Meigs
Mercer
Miami
Monroe
Montgomery
Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren
Washington
Wayne
Williams
Wood
Wyandot
* Site:
* Email Address:
* Week Start Date:
* Week End Date:
* Total Hours:
Notes:
Last Name
First Name
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
*
I certify that the above services were rendered in accordance with the recipient's individual service plan as well as federal and state law and request that Primary Solutions submit these claims on my behalf. I understand: 1) Any false claims, statements, documents or concealments of a material fact may be prosecuted under federal or state laws; 2) This form is to be used solely for billing claim submission to Primary Solutions; 3) This form does not replace original service delivery documentation required by DODD, CMS, and/or the County Board of Developmental Disabilities.
Instructions:
Report billable staff hours for the week in "Total Hours"
Record consumer attendance by checking the checkboxes for days consumers received service