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 Service Individual Counseling Group Counseling Parent Counseling/Training Educational Team Planning and Participation School Consultation Court/Due Process Hearing Testimony Level of Care 13 15 16 35 37 38 Grand Total Cost by Type of Service
Date
Signature of Authorized Representative Print Name and Title For DOE Use Only
Date
_____________ 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' Last Name 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
Students' First Name
Student ID#
School/ Location
Remarks:
*
Level of Care Codes
See attached (LOC)
Date Service Delivered
Level of Care *
Name of Individual Provider
Start Time
End Time
# of Units
Date: Invoice # Page ___of___
Unit Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Sub Total
Cost of Services -
Type of Service Individual Counseling Group Counseling Parent Counseling/Training Educational Team Planning and Participation School Consultation Court/Due Process Hearing Testimony
Level of Care 13 15 16 35 37 38
Unit(s) of Service
The units provided must be reco increments :
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 5 10 15 20 25 30 35 40 45 50 55 60 Units 1 2 3 4 5 6 7 8 9 10 11 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.