With each submission of data, a transmittal record shall also be supplied that contains the following information:

1. (a) Submitting health care facility name;
2. (b) Submitting health care facility tax ID number;
3. (c) Submitting health care facility Medicare provider number;
4. (d) If different from submitting health care facility, the name and address of the location where discharges in the submitted records occurred;
5. (e) File name;
6. (f) Contact person name;
7. (g) Contact person telephone number;
8. (h) Contact person e-mail address;
9. (i) Date processed;
10. (j) Time processed;
11. (k) Submission date; and
12. (l) Explanatory notes to assist with processing of the file.

Source. # 9436, eff 3-21-09, EXPIRED: 3-21-17 New. #12139, INTERIM, eff 3-22-17, EXPIRED: 9-18-17 New. #13369, eff 4-20-22 (formerly He-C 1503.06)