Provider Agency:
Address:
To:
(Name of District)
Address:
This is to request payment for services provided to students during the month of:
ATTACHED: Invoice Detail Sheet
I certify that services were rendered
and invoice(s) is/are true and correct.
I certify invoice(s) is/are an original.
Signature of Authorized Representative
Print Name and Title
If applicable: Corrected Invoice
Reference Invoice dated:
Invoice Number:
For DOE Use Only
Invoice returned for the following reasons:
1. Missing Data _______________________________________
2. Services do not match with:
a._________________________________________________
b._________________________________________________
c._________________________________________________
3. Other: ____________________________________________
4. Date Invoice Returned:
me of District)
es provided to students during the month of:
Type of Level Cost by
Service of Care Type of Service
Individual Counseling 13
Group Counseling 15
Parent Counseling/Training 16
Educational Team Planning and Participation 35
School Consultation 37
Court/Due Process Hearing Testimony 38
Grand Total
Date
Signature of Authorized Representative Date
Print Name and Title
For DOE Use Only
_____________
____________ Payment Number:
____________
____________ Purchase Order Number:
_____________
Contract Log Number:
Date:
Invoice No.
Page ___of___
For DOE Use Only
Date Invoice R'cd
Services rendered validated against serv auth work order forms:
District Contracts Representative (Full Signature)
Approved for Payment
District Educational Specialist
or Designated Representative (Full Signature)
Order Number: Partial
Final
og Number:
Provider Agency
District
Students' Students'
Last First Student School/
Name Name ID# Location
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Remarks:
* Level of Care Codes See attached (LOC)
Date
Service Level of Name of Start End # of
Delivered Care * Individual Provider Time Time Units
Date:
Invoice #
Page ___of___
Unit Cost of
Rate Services
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Sub Total $ -
Type of Service Level of Care Unit(s) of Service
Individual Counseling 13 The units provided must be reco
Group Counseling 15 increments :
Parent Counseling/Training 16
Educational Team Planning and Participation 35
School Consultation 37
Court/Due Process Hearing Testimony 38
INSTRUCTIONS:
1. Signature on invoice summary form is someone who has the authority to request for payment.
2. Invoice no. Is your own internal invoice/billing number. Enter your invoice number on each sheet. This will help to match the
3. Invoice(s) will be rejected in its entirety if
a. Any information does not match with work orders.
b. Totals do not match up.
c. Missing information or documents.
d. Our requirement to pay within 30 days upon receipt of the invoice ends.
4. Corrected Invoice
a. Requirement to pay within 30 days re-starts upon the receipt of the corrected invoice.
b. Please sign and print name.
c. If you choose to use a different Invoice Number for your corrected invoice, please reference the original invoice number a
5. Please submit the invoice summary form and the supporting invoice detail form.
Unit(s) of Service
s provided must be recorded in five (5) minute
Minutes Units
5 1
10 2
15 3
20 4
25 5
30 6
35 7
40 8
45 9
50 10
55 11
60 12
t. This will help to match the invoice detail sheet to the invoice summary sheet.
he original invoice number and date you are replacing/correcting.