Ood Vr Case Services Invoice

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 / $0.00$50.00$75.00
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).
Service Goals/
Referral Requests/
recommendations

NOTE: Providers must use the “Tab” or the arrow keys to move between fields in the form in order to use the auto-calculation feature. If you use “Enter” the field will not be included in the calculation.

CONSUMER: / MONTH/YEAR: / AUTHORIZATION:
DATE / UNITS OF SERVICE (INDIVIDUAL) / UNITS OF SERVICE (GROUP) / BILINGUAL UOS
(INDIVIUDAL) / MILEAGE / TYPE OF
CONTACT / Comments
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
0 / 0 / 0 / 0 / EMFFCLTRMSGRSHSTFTCTXTVC
TOTALS / 0 / 0 / 0 / 0
JOB TASK / EMPLOYER STANDARD / INITIAL PERFORMANCE LEVEL
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
10.
CONSUMER: / MONTH/YEAR: / AUTHORIZATION:
DATE / HYGIENE / INTER-PERSONAL / SELF-DIRECTION / TIMELINESS / WORK ETHIC / JOB TASK 1 / JOB TASK 2 / JOB TASK 3 / JOB TASK 4 / JOB TASK 5 / JOB TASK 6 / JOB TASK 7 / JOB TASK 8 / JOB TASK 9 / JOB TASK 10 / COMMENTS
SUMMARY & RECOMMENDATIONS (Providers have the option of using this section or the “Comments Section” above at the end of the billing cycle to answer the questions in the “Requirements Section” of the VR Fee Schedule.)

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