Filetype Excel XLSX | Posted on 08 Aug 2022 | 3 years ago
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208x Filetype XLSX File size 0.05 MB Source: www.cdph.ca.gov
Sheet 1: FSIE Award Invoice Template
| FOOD, SHELTER, INCENTIVES AND ENABLERS (FSIE) | |||||||||||
| ALLOTMENT INVOICE | |||||||||||
| FY 2018-2019 | |||||||||||
| Invoice must be submitted on city/county letterhead | |||||||||||
| Billing Period: | Award Number: | Total Invoice Amount | $- | ||||||||
| Category | Allotment | Year-to-Date | Current Quarter | Total Amount | Balance Remaining | ||||||
| [A] | [B] | [C] | [B + C] = [D] | [A - D] | |||||||
| Shelter | $- | $- | $- | ||||||||
| Food, Incentives and Enablers | $- | $- | $- | ||||||||
| Total | $- | $- | $- | $- | $- | ||||||
| Hotel/Shelter Detail (Attach supplemental sheet if necessary) | |||||||||||
| SUSPECTED CASE ID # | RVCT # | DOT (Yes/No) | *SHELTER NAME/CATEGORY | RATE PER DAY | # OF DAYS | TOTAL AMOUNT | |||||
| 1 | $- | ||||||||||
| 2 | $- | ||||||||||
| 3 | $- | ||||||||||
| 4 | $- | ||||||||||
| 5 | $- | ||||||||||
| 6 | $- | ||||||||||
| 7 | $- | ||||||||||
| 8 | $- | ||||||||||
| TOTAL HOUSING COST: | $- | ||||||||||
| Food, Incentives and Enablers Detail | |||||||||||
| (Itemize these expenses in the following categories and cross-foot each type of expenditure) | |||||||||||
| o Meals | Category | Number of Items | Cost per | Total | Cost | ||||||
| o Food coupons and vouchers | Item | ||||||||||
| o Clinic juices and snacks for cases and contacts | $- | ||||||||||
| o Personal care items | $- | ||||||||||
| o Other (specify): | $- | ||||||||||
| $- | |||||||||||
| $- | |||||||||||
| $- | |||||||||||
| $- | |||||||||||
| TOTAL FOOD, INCENTIVES AND ENABLERS COST: | $- | ||||||||||
| CERTIFICATION: | |||||||||||
| This reimbursement (invoice) request is certified to be correct and is supported by accounting information and documentation held available for the State | |||||||||||
| Tuberculosis Control Branch review. | |||||||||||
| AUTHORIZED SIGNATORY NAME | AUTHORIZED SIGNATURE | TITLE | |||||||||
| DATE | TELEPHONE NUMBER | ||||||||||
| See the Tuberculosis Control Local Assistance Standards and Procedures Manual Part 3, 1.6B for instructions | |||||||||||
| URL to the Tuberculosis Control Local Assistance Standards and Procedures Manual: | |||||||||||
| https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/TBCB-SPM-Manual-18-19.pdf | |||||||||||
| Bill to: | Remit To: | ||||||||||
| California Department of Public Health | |||||||||||
| Tuberculosis Control Branch | |||||||||||
| 850 Marina Bay Parkway, Bldg. P, 2nd Floor | |||||||||||
| Richmond, CA 94804-6403 | |||||||||||
| Attention: Fiscal Analyst | |||||||||||
| FOOD, SHELTER, INCENTIVES AND ENABLERS (FSIE) | |||||||||
| INVOICE INSTRUCTIONS | |||||||||
| Invoice must be submitted on city/county letterhead | |||||||||
| Hotel/Shelter Detail | |||||||||
| List by patient, include the Report of Verified Case of Tuberculosis (RVCT) and/or Suspected Case Identification (ID) number; | |||||||||
| indicate “Yes” if the patient is on directly observed therapy (DOT) while housed or “No” if the patient is not receiving DOT when | |||||||||
| housed. To receive reimbursement for housing, the patient must have received DOT while housed. If a patient is not receiving DOT, | |||||||||
| please include a statement explaining why not. Indicate the shelter name, type, rate per day or month, number of days shelter was | |||||||||
| provided and total cost. Please do not include patient identifiers, such as name, address, or birth date. | |||||||||
| Creating a Case ID Number for a Patient Suspected of Having TB | |||||||||
| A Suspected Case ID number is coded as follows: last 2 digits of the calendar year, the two digit jurisdiction code number, the letters | |||||||||
| “SP” and the next available number in a sequence which starts at “0001” for each calendar year. An example of the first suspected | |||||||||
| case ID number for the year 2018 is 18XXSP0001. Your two digit jurisdiction code number is the same as the third and fourth | |||||||||
| digits of your FSIE Allotment award number. | |||||||||
| When to Use a Suspected Case ID Number, an RVCT Number or Both Numbers | |||||||||
| Use a Suspected Case ID number if the patient is a suspected of having TB but has not yet been diagnosed with TB. If the patient | |||||||||
| suspected of having TB is subsequently diagnosed with TB, also include the RVCT number. If the patient is a verified case upon | |||||||||
| entry into the housing program, enter the RVCT number only. | |||||||||
| How to code the Category of Shelter Type (code each type of shelter used as follows): | |||||||||
| A - Hotel, Motel, Single Room Occupancy (SRO), YMCA | |||||||||
| B - Private Home or Apartment (do not include the name of the person who owns or rents the shelter) | |||||||||
| C - Rehabilitation Center | |||||||||
| D - Board and Care, Adult Residential Facility | |||||||||
| E - Skilled Nursing Facility | |||||||||
| F - Hospital | |||||||||
| G - Other (specify) | |||||||||
| SUSPECTED CASE ID # | RVCT # | DOT (Yes/No) | SHELTER NAME/CATEGORY | RATE PER DAY | # OF DAYS | TOTAL AMOUNT | |||
| 11XXSP0001 | Yes | Alameda Motel/A | $25.00 | 14 | $350.00 | ||||
| 11XXSP0002 | 2011CA1XX456001 | Yes | Antelope Valley Rehab/C | $45.00 | 10 | $450.00 | |||
| 2011CA1XX457002 | Yes | Clover Motel/A | $25.00 | 20 | $500.00 | ||||
| Total Housing Cost | $1,300.00 | ||||||||
| FSIE Detail | |||||||||
| Itemize these expenses in the following categories and cross-foot each type of expenditure (for complete instructions, see the | |||||||||
| Tuberculosis Control Local Assistance Funds Standards and Procedures Manual). | |||||||||
| o Meals | |||||||||
| 6 patients @ $15/day = $90 | |||||||||
| 2 patients @ $50/day = $100 | |||||||||
| o Food coupons and vouchers | |||||||||
| McDonald’s food vouchers -10 @ $10 = $100 | |||||||||
| Vons gift certificates - 10 @ $50 = $500 | |||||||||
| o Juice and snacks | |||||||||
| Langers juice - 10 @ $6.48 = 64.80 | |||||||||
| Kellogg’s Fruit Snacks - 5 @ $6.98 = $34.90 | |||||||||
| o Personal care items | |||||||||
| Target Gift Card for case to obtain personal care items - 6 @ $10= $60 | |||||||||
| o Other (specify) | |||||||||
| Bus tokens - 30 @ $2 = $60 | |||||||||
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