OOD VR CASE SERVICES INVOICE TEMPLATE 2: COMMUNITY BASED ASSESSMENT, JOB COACHING, & JOB READINESS SERVICES (WA, JRT, & SYWE) 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 Provider Name (MUST MATCH EXACTLY AS IT APPEARSON THE VR ORIGINAL AUTHORIZATION & BILLING INVOICE Provider Mailing Address FORM OOD-0020) City, State Zip Code Telephone PROVIDER STAFF NAME(S) (IF MULTIPLE STAFF PROVIDED SERVICES THEIR NAMES MUST BE LISTED HERE AND Provider Staff Name(s) 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 (INDIVIDUAL) # UOS Individual Rate $0.00 UNITS OF SERVICE BILLED (GROUP) # UOS Group Rate $0.00 UNITS OF SERVICE BILLED (INDIVIDUAL BILINGUAL) # UOS Individual Bilingual Service $0.00 Rate UNITS OF SERVICE BILLED (GROUP BILINGUAL) # UOS $0.00 FLAT FEE SERVICE # Units Flat Fee Rate $0.00 REPORT FEE $0.52 MILEAGE BILLED Miles (Whole #) $0.00 $1.03 WAGE ADD-ON BILLED (IF APPLICABLE) # UOS Wages $0.00 TRANSPORTATION (IF APPLICABLE) # UOS UOS # Miles Rate $0.00 EQUIPMENT OR ITEMS (IF APPLICABLE) Item 1 Description Item 1 Cost (MUST BE ITEMIZED. MAY ATTACH ADDITIONAL SHEET(S) IF NECESSARY. Item 2 Description Item 2 Cost TOTAL COST PUT INTO RIGHT COLUMN.) Item 3 Description Item 3 Cost Item 4 Description Item 4 Cost CHECK IF ADDITIONAL SHEET(S) Item 5 Description Item 5 Cost $0.00 INVOICE TOTAL Total Amount Invoiced PLEASE NOTE: PROVIDERS MUST SUBMIT A PROPER INVOICE, WHICH INCLUDES THE REPORT, WITHIN 15 DAYS OF THE END OF THE SERVICE OR MONTH, WHICHEVER OCCURS FIRST PER THE VR FEE SCHEDULE (OAC 3304-2-52 APPENDIX A).
OOD VR CASE SERVICES INVOICE TEMPLATE 2: COMMUNITY BASED ASSESSMENT, JOB COACHING, & JOB READINESS SERVICES (WA, JRT, & SYWE) 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 $0.00 UNITS OF SERVICE BILLED (GROUP) # UOS Group Rate $0.00 UNITS OF SERVICE BILLED (INDIVIDUAL BILINGUAL) # UOS Individual Bilingual Service Rate $0.00 UNITS OF SERVICE BILLED (GROUP BILINGUAL) # UOS $0.00 FLAT FEE SERVICE # Units Flat Fee Rate $0.00 REPORT FEE MILEAGE BILLED Miles (Whole #) $0.52 $0.00 WAGE ADD-ON BILLED (IF APPLICABLE) # UOS Wages $1.03 $0.00 TRANSPORTATION (IF APPLICABLE) # UOS # Miles UOS Rate $0.00 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 $0.00 Item 2 Description Item 2 Cost Item 3 Description Item 3 Cost Item 4 Description Item 4 Cost Item 5 Description Item 5 Cost INVOICE TOTAL Total Amount Invoiced PLEASE NOTE: PROVIDERS MUST SUBMIT A PROPER INVOICE, WHICH INCLUDES THE REPORT, WITHIN 15 DAYS OF THE END OF THE SERVICE OR MONTH, WHICHEVER OCCURS FIRST PER THE VR FEE SCHEDULE (OAC 3304-2-52 APPENDIX A).
Provider%20Report%20Template%202%20-%202017%20WORD.docx