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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:
* Consumer Name:
* Email Address:
 Notes:

Date of
Service
Routine Personal CareOn Site/On Call (Sleep)TransportationService
Location
(County)
Staff
Size
Group
Size
UnitsOvertime
Units
Staff
Size
Group
Size
UnitsOvertime
Units
Group
Size
Units
C = Display Calendar; X = Delete Row

*
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.

Starting January 1, 2016, the Ohio Department of Developmental Disabilities (DODD) will make overtime payments to eligible independent providers billing over 40 hours, or 160 fifteen-minute units of service provided in a work week. The State of Ohio has defined a work week as Sunday, 12:00 a.m. to Saturday, 11:59 p.m. If you have questions regarding your eligibility to provide overtime, The DODD Support Center is available at 800-617-6733.

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