Instructions for the IB Services Product Fee Verification Form

Agency Name / Enter the name of agency as identified on the IB Services Contract
Agency Code / Enter the agency’s five digit code as provided by the DDSO after the Program Code is established
Contract Number / Enter the contract number assigned to IB Services (starts with C0609XX)
Program Code / Enter the eight digit code attached to your IB Services Contract
Contact Person / Enter the first and last name of a staff person that can answer any questions regarding this completed form
Contact Person’s Secure Message Center E-mail Account Address / Enter the contact person’s SMC account where they can be reached
Contact Person’s Phone Number / Enter the contact person’s phone number. Be sure to include the area code
Individual’s Last Name / Enter the individual’s last name for whom the BMP & FBA was completed
Individual’s First Name / Enter the individual’s first name for whom the BMP & FBA was completed
Individual’s CIN / Enter the individual’s Medicaid Consumer Identification Number (CIN) for whom the BMP & FBA was completed
Individual’s TABS ID / Enter the individual’s Tracking and Billing Systems (TABS) Identification number
Date the FBA & BMP were completed / Enter the date on which the Behavior Management Plan was completed. The date needs to include month, day and year.
Staff person’s Last Name / Enter the last name of the supervisor who has an NPI or the staff person who completed the BMP & FBA if that person has an NPI
Staff person’s First Name / Enter the first name of the supervisor who has an NPI or the staff person who completed the BMP & FBA if that person has an NPI
NPI / Enter the NPI (10 digits) of the supervisor who has an NPI or the staff person who completed the BMP & FBA if that person has an NPI. The supervisor or the staff person identified needs to meet the experiential and educational criteria specified for delivering, or supervising the delivery of IB Services
Is this a resubmitted Form (check box, if yes) / Check this box if your agency has already submitted the verification form for payment of the product fee for this individual and this form contains changes to that original submission.
Describe the change: / Describe the changes that you are making to the original submission. NOTE – All fields must be completed on a resubmitted form, including fields which were completed correctly on the original submission
Authorized by / Enter the first and last name of the staff person who is attesting that the FBA and BMP were completed on or before the date listed above. It is expected that the person attesting to the completion to have reviewed the FBA and BMP to confirm the completion.
Date / Enter the date that the staff person listed in the “authorized by” box is attesting that the FBA and BMP were completed. The date needs to include month, day and year.
Completed forms should be submitted via a Secure Message Center (SMC) account to

v. 6/17/10