Form 2455-S - Supplemental Billing Form - Workforce Solutions

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Workforce Solutions
PROVIDER:___________________________#________
Month___ Year___ 1st __ 2nd __ Full __
Supplemental Billing Form 2455-S
BILLING SHOULD BE IN ALPHABETICAL ORDER BY LAST NAME AND HAVE AN AUTHORIZED REASON
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Child Last/First Name
Units
ABS
ILL
Reason:
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I certify that the above information is correct.
Signature: _________________________________
DATE: __________________________________
Claiming for services not provided is FRAUD

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