FOSTER PARENT BILLING INVOICE

Foster Parent Name: ______Month/Year: ______

Address: ______

City:______State: ______Zip: ______

Phone #: ______

Children Placed in Home

Child’s Name / Dates Child in Home / # of Days

Children Placed in Respite: An encompass Respite Form must be completed, signed by BOTH Foster Parents, attached to this billing and have been provided less than 90 days prior for any payment to be made.

Child’s Name / Child’s Foster Parent / Date & Time Placed / Date & Time Left / Form
Attached

Totals from Each Section:

Total

/ Office Use
Training Hours / Total from Page 2
Refundable Expenses / Total from Page 2
Mileage / Total from Page 2

I hereby certify that the Dates of Care, Training Hours, Refundable Expenses & Mileage are correct and that payment in whole or in part has not been received.

______

Foster Parent Signature (Required)Date

Foster Parent Name, Month and Year: ______

Page 2

Foster Parent Training: A completed encompass Training Evaluation Form must be attached to receive payment and/or credit for any training.A maximum of 40 or 60 hours are reimbursed per licensure period

(2 years) per person, depending on your level of licensure. Training must have been completed less than 120 days from the date of billing being processed. For Books 100pages =3 hrs

Name & Location of Training / Date / Who Attended / # of Hours / Face 2 Face
Y or N

Refundable Expenses:Must be Pre-Approved by encompass & receipts must be attached to this billing statement.

Description of Expense / Date of Expense / Amt Paid

Mileage:All mileage must be approved by encompass. Transportation for visits with bio-family & for respite will be reimbursed. Counseling/medical appointments over 50 miles round trip will be reimbursed. Exceptional and/or excessive medical or counseling visits fewer than 50 miles may be reimbursed only if pre-approved by the encompass director. All other transportation is covered by your per diem.

Date / Round Trip Miles / Address of Destination / Reason / Child’s Name / encompass
Use ONLY