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          24:14:04:22.  Claim requirements. A claim for services provided under this chapter must be submitted on a form which contains the following information:

          (1)  The provider's name, address, and phone number;

          (2)  The provider's employer identification or social security number;

          (3)  The client's full name;

          (4)  Type of service;

          (5)  Dates of service;

          (6)  Units of service provided;

          (7)  The unit price;

          (8)  If claiming mileage or travel time reimbursement, the destination must be listed; and

          (9)  Signature of the claimant.

          Source: 26 SDR 153, effective May 22, 2000.

          General Authority: SDCL 13-37-1.1

          Law Implemented: SDCL 13-1-23, 13-14-1, 13-37-1.1


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