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20.5.2.5 Paper Form: Family Planning 2017 Claim Forms in a Title X-Supported Clinic
Titles V, XIX, and XX
Clients eligible for Title V, XIX, or XX must have the funding source to which the claim is billed checked in Block 1 of the Family Planning 2017 claim form. Block 28, Level of Practitioner, must be completed for every Family Planning 2017 claim form submitted by a clinic that uses Title X funds.
Title X Only
The payment level must be selected in the Title X Only section of Block 1a. Depending on family size and income, the agency designates Title X clients as full pay, partial pay, or no pay for services. Block 28, Level of Practitioner, must also be completed.
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