REQUIRED FIELDS ARE INDICATED WITH ASTERISK AND RED FIELD NAME
                                                                                             USE THE ENTER KEY TO MOVE FROM CELL TO CELL
                                                                                             USE DROP DOWN LISTS WITH MOUSE OR [ALT]+[DOWN ARROW]
                                                                                             ONLY ONE INVOICE PER EXCEL WORKBOOK
                                                                                              - IF MORE THAN ONE INVOICE IS TO BE SUBMITTED USE THE PDF VERSION OR EXCEL (WITH MACROS)
                                                                                             SAVE WITH A UNIQUE FILE NAME BEFORE SUBMISSION
            Billing Provider Information              Value
            *National Provider Identifier (NPI)
            *Tax Identification Number (TIN)
            *Provider's last/Organization name
            Provider's first name
            *Address
            *City
            *State
            *ZIP
            *Phone number
            Rendering Provider Information            Value
            National Provider Identifier (NPI)
            *Tax Identification Number (TIN)
            *Provider's last/Organization name
            Provider's first name
            *Address
            *City
            *State
            *ZIP
            *Phone number
       REQUIRED FIELDS ARE INDICATED WITH ASTERISK AND RED FIELD NAME
       USE THE ENTER KEY TO MOVE FROM CELL TO CELL
       USE DROP DOWN LISTS WITH MOUSE OR [ALT]+[DOWN ARROW]
       ONLY ONE INVOICE PER EXCEL WORKBOOK
        - IF MORE THAN ONE INVOICE IS TO BE SUBMITTED USE THE PDF VERSION OR EXCEL (WITH MACROS)
       SAVE WITH A UNIQUE FILE NAME BEFORE SUBMISSION
            Member Information                                Value
            *Member Client Identification Number (CIN)
            Member Homeless Indicator
            *Last name
            *First name
            *Date of Birth (Mo./Day/Yr.)
            *Residential Address
            *City
            *State
            *ZIP
            *Insured's or Authorized Person's Signature.
            *I authorize payment of Community Supports services to the undersigned physician or supplier for 
            services described below.
            Payor and Diagnosis Information                   Value
            *Payor Primary ID
            Payor Name
            *Diagnosis A
            *Diagnosis B
            *Diagnosis C
            *Diagnosis D
            *Diagnosis E
            *Diagnosis F
            *Diagnosis G
            *Diagnosis H
            *Diagnosis I
            *Diagnosis J
 - IF MORE THAN ONE INVOICE IS TO BE SUBMITTED USE THE PDF VERSION OR EXCEL (WITH MACROS)
                     Service Information                           Value                                                                      Administrative Information
                     *Service start date (1)                                                                                                  *Invoice Date (Mo./Day/Yr.)
                     *Service end date (1)                                                                                                    *Invoice #
                     *Place of service (1)                                                                                                    Control #
                     Service name (1)                                                                                                         Attachments
                     *Procedure (1)                                                                                                           Authorization ID #
                     *Modifier(s) (1)                                                                                                         Submission Type
                     *Diag # (1)                                                                                                              Original Claim ID
                     *Service unit count (1)                                                                                                  *Signed
                     *Service unit cost (1)                         $                                                           -             *Date
                     Charge Amount (1)                              $                                                           -   
                                                                                                                                              *Signature of Physician or Supplier (I certify that the statement on the reverse 
                     *Service start date (2)                                                                                                  apply to this bill and are made a part thereof).
                     *Service end date (2)
                     *Place of service (2)
                     Service name (2)
                     *Procedure (2)
                     *Modifier(s) (2)
                     *Diag # (2)
                     *Service unit count (2)
                     *Service unit cost (2)                         $                                                           -   
                     Charge Amount (2)                              $                                                           -   
                     *Service start date (3)
                     *Service end date (3)
                     *Place of service (3)
                     Service name (3)
                     *Procedure (3)
                     *Modifier(s) (3)
                     *Diag # (3)
                     *Service unit count (3)
                     *Service unit cost (3)                         $                                                           -   
                     Charge Amount (3)                              $                                                           -   
                     *Service start date (4)
                     *Service end date (4)
                     *Place of service (4)
                     Service name (4)
                     *Procedure (4)
                     *Modifier(s) (4)
             *Diag # (4)
             *Service unit count (4)
             *Service unit cost (4)       $                                                           -   
             Charge Amount (4)            $                                                           -   
             *Service start date (5)
             *Service end date (5)
             *Place of service (5)
             Service name (5)
             *Procedure (5)
             *Modifier(s) (5)
             *Diag # (5)
             *Service unit count (5)
             *Service unit cost (5)       $                                                           -   
             Charge Amount (5)            $                                                           -   
             *Service start date (6)
             *Service end date (6)
             *Place of service (6)
             Service name (6)
             *Procedure (6)
             *Modifier(s) (6)
             *Diag # (6)
             *Service unit count (6)
             *Service unit cost (6)       $                                                           -   
             Charge Amount (6)            $                                                           -   
             Invoice Amount               $                                                           -