• Jessup Inc RBT Time Sheet

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  • JESSUP, INC.
    DECLARATION OF PROVIDER


    The undersigned provider certifies the following to be true and correct:
    1)  This is a true and correct representation of the services and times the services were provided;
    2)  The provider is properly credentialed to provide such services;
    3)  The provider provided the services in the manner required by law and consistent to the provider's agreement with Jessup, Inc.

    MEDICAID AND INSURANCE FRAUD IS A CRIME!

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  • The undersigned certifies that the {providerTitle} provided the services to patient and times shown above indicate the amount of time the RBT provided the service.   MEDICAID AND INSURANCE FRAUD IS A CRIME!  Please call us if anyone attempts to certify times that are inaccurate or services that were not provided.

    Our Phone Number is 386-878-2400

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