The provider shall submit the following documents: A request for payment on a form designated by the Department; A bill that specifies the: Name of the emergency evaluee; Date of service; and Description of service; A copy of the current petition for emergency evaluation; If the bill is for an examination by a consultant physician, a copy of the consultant physician's evaluation that is signed by the examining consultant physician; If the bill is for transportation of an emergency evaluee from a designated emergency facility to an inpatient facility, copies of both completed certificates for involuntary admission and the application for involuntary admission; and Any other documentation required by the Department to determine that the conditions of this chapter have been met. The provider shall submit the request for payment within 12 months of the date of service. The Department may refuse a request for payment if the request is not accompanied by properly completed forms and documents required under §A of this regulation.