Free Form 02AS001E (ADM-12-ADS-SI) Instructions - Oklahoma

Adult Day Service Invoice Purpose of form

02AS001I (ADM-12-ADS-SI)

This form is used by the vendor to claim payment for Department (DHS) authorized day services provided to eligible individuals. Instructions An original and one copy are prepared by the facility operator or designee. Date: Enter date form is prepared, giving month, day and year.

Identifying information.
Federal ID no.: Enter your facility's federal identification number. Contract no.: Enter the contract number found on the Purchase Order (PO#) from the Department of Central Services. Note: This number changes each fiscal year (July 1st). Contractor: Enter name of person, agency, organization, or firm to which the Department is indebted. The name of the contractor shown here must be identical to the name of contractor on Service/Attendance/Claim Record, Form 02AS004E. Address: Enter the address to which the payment is to be mailed. Give street address, post office box, or rural route number, city, state, and zip code. Location: If the facility provides services under the same federal identification number in more than one location or facility, indicate the location covered in this claim provided.

Part I. Claimed items: This part of the Service Invoice is completed by the facility
operator or designee. Purchase of adult day services for the calendar month of: Enter the month and year covered by the claim. Total number of persons: Enter total number of attached Form(s) 02AS004E Service/Attendance/Claim Record. There should be one Form 02AS004E for each eligible person receiving authorized/compensable services during the month. Amount claimed: Add the amount of charges on all Form(s) 02AS004E and enter the total amount claimed.

Part II. Audit approval: Reserved for Approving Office Use Only. This blocked
section should be left blank by the claimant for completion by audit unit. Number of persons disallowed by approving office: The Approving Office reviews all Form(s) 02AS004E(s) attached to this claim for correctness, completeness and compensability. If an error is made (e.g., rates, charges, amount claimed, case number, family member number, etc.), that form(s) is returned to the claimant for correction or clarification. Number of persons approved: Enter the number of persons approved after subtraction of number of persons disallowed on Form(s) 02AS004E returned to claimant. Enter amount approved after subtraction of the total amount disallowed on the Form(s) 02AS004E returned to the claimant. Issued 7-1-2000 Page 1 of 2

02AS001I (ADM-12-ADS-SI)

Adult Day Service Invoice

Unit approval title and location: The invoice is signed by the approving office or designee and the title and location entered in space provided. Date: Enter the date audit is completed. Contractor signature: The facility owner/operator or person legally authorized to transact business signs and dates the form(s) after services being claimed have been provided. Routing Contractor: Original and one copy are attached to the front of Form 02AS004E and sent to Aging Services Division within 30 days of the last day of service. The copy is retained in your file.

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Issued 7-1-2000