STATE MATCH VERIFICATION RECIPIENT NUMBER PROVIDER INFORMATION PROVIDER NAME PROVIDER ID NUMBER PROVIDER SPECIALTY SERVICE DATES BEGIN END UNITS OF SERVICE STATE MATCH PAID TOTAL u SIGNATURE TITLE DATE INSTRUCTIONS RECIPIENT INFORMATION: Enter the 10-digit Recipient Number exactly as it appears on the CMS-1500, the 837 electronic format, and/or the recipient's Pennsylvania ACCESS Card. PROVIDER INFORMATION: Provider Name - enter the name of the targeted services management entity providing the service. Provider ID Number - enter the thirteen-digit PROMISe identification number assigned to the provider. Provider Specialty - enter "218" for Intellectual Disability Targeted Service Management. SERVICE DATES: Begin Date - if the same service was provided on consecutive days, enter the first day of service. End Date - this date will indicate the date of service if the service was provided on only one day; or the last consecutive day the same service was provided. Units of Service - enter the number of times the service was performed on the same or consecutive days. State Match Paid - enter the dollar amount paid to the provider by the county for these units of service. Signature/Title - signature and title of authorized county representative. Date - enter today's date. American LegalNet, Inc. www.FormsWorkFlow.com COUNTY/PROVIDER COPY MA 791 5/15