1. (a) The individual requesting payment or the funeral director on behalf of the individual requesting payment shall submit the request on a form approved by the Department in accordance with § 283.7 (relating to date of request for payment). This form is available from the Department or a funeral director enrolled as a provider with the Department.

2. (b) The form shall be completed by the individual requesting payment and the funeral director. The form must include the following information:

   1. (1) Name and Social Security number of the deceased.
   2. (2) Name and signature of the representative requesting payment on behalf of the deceased.
   3. (3) Resources available towards payment.
   4. (4) Name and address of the funeral home.
   5. (5) Name and signature of the funeral director providing goods and services for burial or cremation, or both.

Cross References

This section cited in 55 Pa. Code § 283.3 (relating to requirements for payment).