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:
* 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