Form Amh 0493 R is the form you use to report the sale or other disposition of real property. This form must be filed with the Kentucky State Tax Commission within fifteen days of the sale or disposition. The purpose of this form is to document the information necessary to determine the amount of tax that is due on the transaction. There are a few things you will need to know before you fill out this form, so keep reading for more information.
| Question | Answer |
|---|---|
| Form Name | Form Amh 0493 R |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | DHS, pasrr oregon, Alondra, AMH |
Request for Payment
Addictions and Mental Health Division (AMH)
Provider Name
Address
Federal Tax ID
Provider Number
Client Name
Date of Service
Procedure Code
Amount Due
Total Due ______________
Providers must bill at rates based on the cost of services determined through a cost allocation plan, not in excess of their usual and customary charge to the general public (OAR
T2010 PASRR Level I Identification and Screening, for the purpose of billing, means the Resident Review/Brief Consultation & Screening. T 2011 PASRR Level II MH Evaluation – Comprehensive Evaluation
T1013 Sign Language/Oral interpreter services are allowed only when provided in conjunction with another service such as an assessment for the duration of the service.
For current rates, see most recent publication of “MH Procedural Codes and Reimbursement Rates and Table (most recent date)” at www.oregon.gov/DHS/mental health/publications/main.shtml. For additional billing forms contact Addictions and Mental Health at
SignatureDate
For AMH Use Only
Telephone Number
AMH 0493 R (12/07)
Mail To: Alondra Rogers
DHS/AMH/PASRR
500 Summer St NE E 86
Salem, OR