OOD VR CASE SERVICES INVOICE TEMPLATE 1: JOB PLACEMENT ASSISTANCE & RETENTION INVOICE DATE: Invoice Date INVOICE STATUS: FINAL INVOICE OR PARTIAL INVOICE VR AUTHORIZATION #: VR Authorization # PARTICIPANT NAME: Participant Name VR STAFF NAME: VR Staff Name PROVIDER NAME, ADDRESS, & Provider Name Provider Mailing Address TELEPHONE City, State Zip Code (MUST MATCH EXACTLY AS IT APPEARSON THE VR Telephone ORIGINAL AUTHORIZATION & BILLING INVOICE FORM OOD-0020) PROVIDER STAFF NAME(S) Provider Staff Name(s) (IF MULTIPLE STAFF PROVIDED SERVICES THEIR NAMES MUST BE LISTED HERE AND THE REPORT SHOULD CLEARLY INDICATE WHO PERFORMED WORK PER THE VR PROVIDER MANUAL.) PROVIDER INTERNAL INVOICE # (IF APPLICABLE): Provider Internal Invoice # SERVICE START DATE: Service Start Date SERVICE END DATE: Service End Date SERVICE NAME: Service Name SERVICE QUANTITY RATE TOTAL COST UNITS OF SERVICE BILLED # UOS Individual Rate (INDIVIDUAL) UNITS OF SERVICE BILLED (GROUP) # UOS Group Rate UNITS OF SERVICE BILLED # UOS Individual Bilingual (INDIVIDUAL BILINGUAL) Service Rate UNITS OF SERVICE BILLED (GROUP # UOS BILINGUAL) FLAT FEE SERVICE # Units Flat Fee Rate REPORT FEE MILEAGE BILLED Miles (Whole #) $0.52 WAGE ADD-ON BILLED (IF # UOS Wages $1.03 APPLICABLE) TRANSPORTATION (IF APPLICABLE) # UOS UOS # Miles Rate EQUIPMENT OR ITEMS Item 1 Description Item 1 Cost Item 2 Description Item 2 Cost (IF APPLICABLE) Item 3 Description Item 3 Cost (MUST BE ITEMIZED. MAY ATTACH Item 4 Description Item 4 Cost ADDITIONAL SHEET(S) Item 5 Description Item 5 Cost IF NECESSARY. TOTAL Item 6 Description Item 6 Cost COST PUT INTO RIGHT Item 7 Description Item 7 Cost COLUMN.) Item 8 Description Item 8 Cost CHECK IF ADDITIONAL SHEET(S) INVOICE TOTAL Total Amount Invoiced
OOD VR CASE SERVICES INVOICE TEMPLATE 1: JOB PLACEMENT ASSISTANCE & RETENTION INVOICE DATE: Invoice Date INVOICE STATUS: FINAL INVOICE OR PARTIAL INVOICE VR AUTHORIZATION #: VR Authorization # PARTICIPANT NAME: Participant Name VR STAFF NAME: VR Staff Name PROVIDER NAME, ADDRESS, & TELEPHONE (MUST MATCH EXACTLY AS IT APPEARSON THE VR ORIGINAL AUTHORIZATION & BILLING INVOICE FORM OOD-0020) Provider Name Provider Mailing Address City, State Zip Code Telephone PROVIDER STAFF NAME(S) (IF MULTIPLE STAFF PROVIDED SERVICES THEIR NAMES MUST BE LISTED HERE AND THE REPORT SHOULD CLEARLY INDICATE WHO PERFORMED WORK PER THE VR PROVIDER MANUAL.) Provider Staff Name(s) PROVIDER INTERNAL INVOICE # (IF APPLICABLE): Provider Internal Invoice # SERVICE START DATE: Service Start Date SERVICE END DATE: Service End Date SERVICE NAME: Service Name SERVICE QUANTITY RATE TOTAL COST UNITS OF SERVICE BILLED (INDIVIDUAL) # UOS Individual Rate UNITS OF SERVICE BILLED (GROUP) # UOS Group Rate UNITS OF SERVICE BILLED (INDIVIDUAL BILINGUAL) # UOS Individual Bilingual Service Rate UNITS OF SERVICE BILLED (GROUP BILINGUAL) # UOS FLAT FEE SERVICE # Units Flat Fee Rate REPORT FEE MILEAGE BILLED Miles (Whole #) $0.52 WAGE ADD-ON BILLED (IF APPLICABLE) # UOS Wages $1.03 TRANSPORTATION (IF APPLICABLE) # UOS # Miles UOS Rate EQUIPMENT OR ITEMS (IF APPLICABLE) (MUST BE ITEMIZED. MAY ATTACH ADDITIONAL SHEET(S) IF NECESSARY. TOTAL COST PUT INTO RIGHT COLUMN.) CHECK IF ADDITIONAL SHEET(S) Item 1 Description Item 1 Cost Item 2 Description Item 2 Cost Item 3 Description Item 3 Cost Item 4 Description Item 4 Cost Item 5 Description Item 5 Cost Item 6 Description Item 6 Cost Item 7 Description Item 7 Cost Item 8 Description Item 8 Cost INVOICE TOTAL Total Amount Invoiced
Provider%20Report%20Template%201%20-%202017%20WORD.docx