Informal Care Provider Monthly Invoice Form
Insured Name:
Date Total Hours $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Insured SS Number:
Charges Per Hour $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Charge
Total
Warning: It is a crime to knowingly, and with intent, defraud the insurance company or another person by: (1) filing a claim that contains any materially false information; or (2) concealing, material facts; or (3) providing misleading information. Such actions are fraudulent insurance acts subject to criminal and civil penalties. Detailed description of services provided: Bathing,
Light housekeeping, Meal prep, Laundry, Dressing, Transferring, Toileting, Feeding,
Other (please specify):
Printed Name of Provider: ___________________________ Relation to Insured: _________________________ Address of Provider: ____________________________________________________________________________________________ Social Sec. Number of Provider:
_____________ - ___________ - _____________
**DO NOT SIGN OR DATE UNTIL AFTER SERVICES HAVE BEEN PROVIDED**
For verification please include a photocopy of your Social Security Card, Drivers License, or State Issued ID
Signature of Provider: ___________________________________ Insured’s Signature:
___________________________________________
Date: _______________________ Date :
_____________________________
Long Term Care Partners, LLC, 100 Arboretum Drive, Portsmouth, NH 03801-7833