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  Primary Solutions Billing  
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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:
* Site:
* Email Address:
* Week Start Date: * Week End Date:
* Weekly Total Hours:
* Weekly Longevity Hours:
 Notes:
Last NameFirst NameSunMonTuesWedThursFriSat
Daily Hours:
Longevity Hours:

*
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 "Weekly Total", of that "Weekly Total" list the number of those hours that qualified as Longevity Hours

Record consumer attendance by placing an 'X' in box for dates consumers received service. Record the daily total of Billable hours and the number of those hours that qualify for the Longevity Add on Hours in each box

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