Form Amh 0493 R PDF Details

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.

Form NameForm Amh 0493 R
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesDHS, pasrr oregon, Alondra, AMH

Form Preview Example

---- NON-MEDICAID ----

Request for Payment

Pre-Admission Screening and Resident Review - PASRR

Addictions and Mental Health Division (AMH)

Provider Name


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 309-016-0105 and OAR 309-016-0420).

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 health/publications/main.shtml. For additional billing forms contact Addictions and Mental Health at (503)945-9716.


For AMH Use Only

Telephone Number

AMH 0493 R (12/07)

Mail To: Alondra Rogers


500 Summer St NE E 86

Salem, OR 97301-1118