Hourly Contractor Invoice Template

							                                                                                                      NORTH COUNTRY COMMUNITY MENTAL HEALTH SERVICES
                                                                                                               ONE MACDONALD DRIVE, SUITE A
                                                                                                                    PETOSKEY, MI 49770
                                                                                MONTHLY SERVICES REPORT AND INVOICE FOR HOURLY SIPS

SECTION I                           HEADER INFORMATION

FROM:                                                                                                                                                CONTRACT NO:                                                   COST CENTER NO:
                 Provider/Corporation Name                                           Home Name

                                                                                                                        MI                           CONTRACT RATE:                                                 MONTH OF SERVICE:
                 Street                                                              City                               State        Zip


SECTION II                          CONSUMER SPECIFIC INFORMATION                                                               CHARGES                                                                                                   FOR AGENCY USE ONLY

                                                                                                                                                 Total Rate                   Request for
     Case                          Consumer Name                               Medicaid                         Total                           x Total Hours            Additional Funding                                                Total                 Amount
   Number                (Last)                        (First)                ID Number                         Hours                                Amount           RAF #             Amount                 Net Bill                 Amount +/(-)             Paid +/(-)




SECTION III                         DAILY ATTENDANCE INFORMATION
Indicate the amount of HOURS in each box below for each day services are provided. CONSUMERS SECOND ROW BELOW INDICATE HOURS IN THE DAILY BOX FOR 1:1 SRV'S, WHEN PROVIDED
 CASE NO.                         CONSUMER 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    26      27   28   29    30     31




SECTION IV                          CERTIFICATION AND SIGNATURE
I hereby certify the above represents the true number of consumers and consumer days of service provided for the period                              The information contained on this form is true to the best of my knowledge.
stated, as specified in the individual plans of service. I understand that submission of false data may result in a fine or                          Accounting Signature                                                                           Date
imprisonment in keeping with M.C.L. 400.1 et. Seq., and that failure to submit by the fifth day of each month will result in
non-payment.
Residential Contractor                                                                      Date                                                     Finance Director Approval                                                                      Date



CMH 3806




             Updated: December 16, 2010