Sheet 1: Invoice 

	
	
	
	
	
	

		
FACILITY NAME: 
		


		
CONTRACTOR NAME:
		
	

		
FACILITY ADDRESS: 
		


		
REMIT ADDRESS: 
		
	

		


		


		


		
	

		
PROGRAM RU #: 
		


		
INVOICE CONTACT PERSON/NAME: 
		
	

		
CONTRACT NUMBER:  
		


		


		


	
	

		

INVOICE MONTH AND YEAR: 
		
CONTACT PHONE #:
		
	

		
Service Code
		
Total Units of Service
		
Unit of Service Rate
		
Total Claimed Amount
		
	

		


		
0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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0
		
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TOTALS
		
0
		


		
 $-   
		
	

		
Attestation of Claim: I hereby certify that I am the official who is responsible for claiming the amount of reimbursement specified in the attached documents.  To the best of my knowledge and belief these claims are in all respect true and correct and are completed in accordance with applicable law.  To the best of my knowledge and belief, the services were provided in accordance with clients written treatment plan and the services have been documented in the client record, if applicable.  I understand that payment for these claims may be from Federal and/or State, and/or County funds and that any falsification or concealment of a material fact may be prosecuted under federal and/or State Laws.
		
	

		
	

		
	

		
	

		
	

		
	

		


		


		


		


		


	
	

		


		


		


		


		


	
	

		


		


		


		


		


	
	

		
APPROVED BY FACILITY EXECUTIVE DIRECTOR OR DESIGNEE SIGNATURE:________________________________________________DATE:______________________
		
	

		
PRINT NAME:________________________________________________                                              TITLE:________________________________________________________________
		
	

		


		


		


		


		


	
	

		


		


		


		


		


	



Sheet 2:  Individual Service Log

	
	
	
	
	
	
	
	

		
Month/Year of Service: 
		


		


		
Program/RU:_____________
		
	

		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


	
	

		


		


		


		


		


		
Primary Staff
		
	

		
1.Date of
		


		


		
4.Service
		
6.Service
		
7.Primary
		
8.Duration
	
	

		
Service
		
2.Client ID #
		
3.Client Name
		
Code
		
Location
		
Practitioner #
		
(Billable Minutes)
	
	

		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


	
	

		


		


		


		
Grand Total
		


		


		
0
	



Sheet 3: Group Service Log

	
	
	
	
	
	
	
	
	
	
	
	

		
Month/Year of Service: 
		


		


		


		


		
Program/RU:
		


		
	

		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		
Primary Staff
		
Co-Staff
		
12.Total Billable
	
	

		
1.Date of
		


		


		
4.Service
		
5.Number of
		
6.Service
		
7.Primary
		
8.Duration
		
9. Co-
		
10.Duration
		
Duration
	
	

		
Service
		
2.Client ID #
		
3.Client Name
		
Code
		
Clts In Group
		
Location
		
Practitioner #
		
(Minutes)
		
Practitioner #
		
(Minutes)
		
(Minutes)
	
	

		


		


		


		


		


		


		


		


		


		


		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


		


		


		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


		


		


		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


		


		


		
#DIV/0!
	
	

		


		


		
Grand Total
		
0
		


		


		


		
 -   
		


		
 -   
		
#DIV/0!