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Billing Data More Information

Service Authorization Information

Authorization ID

SA-HTYLIMD-QD64S5ZZHGYFE

Program Name

Day Habilitation

Individual Name

Person, Fake

Authorization Number

Test 0001

Funding Source

GT Independence

Funding Provider Number

Begin Date

10/14/2026

End Date

11/19/2026

Service Coordinator

Service Coordinator Organization

Service Coordinator Number

Service Information

Service Code

DH11

Service Description

Day Habilitation 1:1

Unit of Measure

Quarter Hour

Unit Rate ($)

$5.00

Total Authorized Amount ($)

$0.00

Number of Units

100.00

Billing Data Input

* Service Date

, Required

Time In/Out

#

Time In

Time Out

Units

Remove

1

* Total Billable Units

, Required

Service Remaining Units

100.00

Unit Rate ($)

Total Non-billable Units

Procedure Modifiers

---

Primary Diagnosis Code

ICD-10: F71

Diagnosis Code Pointer

1---

Service Provider

- Please Select -

Happiness Consultant, Consultant/ Admin

Ahmein Watson, Executive Director

Myeika Waller, Dt