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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