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Invoice Help

This document is an invoice voucher for respite care providers working with the Respite Care Network (RCN). It requests information from the respite care provider such as their name, address, social security/tax ID, and contact details. It also includes fields to document the dates and hours of respite provided, total hours, and signatures from the respite care provider and sponsor/parent to confirm the hours worked. Instructions are provided on submitting the invoice by fax each month along with a satisfaction survey.

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brendatdonahue
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© Attribution Non-Commercial (BY-NC)
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Download as DOC, PDF, TXT or read online on Scribd
46 views

Invoice Help

This document is an invoice voucher for respite care providers working with the Respite Care Network (RCN). It requests information from the respite care provider such as their name, address, social security/tax ID, and contact details. It also includes fields to document the dates and hours of respite provided, total hours, and signatures from the respite care provider and sponsor/parent to confirm the hours worked. Instructions are provided on submitting the invoice by fax each month along with a satisfaction survey.

Uploaded by

brendatdonahue
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ALIGNSTAFFING

RESPITE CARE NETWORK (RCN)


RESPITE CARE PROVIDER INVOICE VOUCHER

1. Name of Respite Care Provider: __________

2. Social Security Number or Employer Identification Number: very important the first
time we process your information, after first process last four will suffice. _

3. Address: this will determine where your check goes, please input the correct information here/
AGENCIES: once you are sure that you have provided the accounting department with your mailing
address for billing, you will not be required to put an address just write, “address on file” or “on file”.

4. Telephone: _please put whichever number you would like to be reached on should something not
be correct. Home or Cell.____ Cell: __________________________

5. Fax: ____________ Email Address: only if this is the preferred method of contact

6. Installation: EFMP Manager/Designee:

7. Respite Care Recipient:

8. RCN Case Record Number: I have this number here in the office, do not worry about this
Month/Year: I need to know what month you provided the respite not the month you are
turning in the voucher.

9. Hours Authorized: _________________ Hourly Rate:

10. Fax the payment packet no later than the 4th working day of the following month:

• Invoice Voucher
• Respite Care Provider Satisfaction Survey

Total Total
11. Hours Hours
Date In Out In Out Worked Date In Out In Out Worked
1 17
2 18
3 19
4 20
5 21
6 22
7 23
8 24
9 25
10 26
11 27
12 28
13 29
14 30
15 31
16
12. Grand Total Hours:

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I certify that these hours are true and accurate.

13.
Sponsor/Parent/Guardian Signature Date

I certify that these hours are true and accurate.

14.
Respite Care Provider Signature Date

15. Comments/Notes: PLEASE NOTE: There is no place for an EFMP Manager Signature
nor any other signature besides that of the individual providing respite and the authorizing
signature of the individual confirming that the respite was provided.

AGENCIES: If you would like to initial next to item 14 or next to Item 12 that will be fine,
however it is not necessary for you to sign this document. The above two signatures are the
only ones that have to be on this document for processing. Should you decide to initial in either
of the suggested places please make sure that it is synonymous on all invoices. Sometimes the
fax machine darkens the invoice and it is difficult to read the table with the indicated hours. The
initials may be more difficult to read. If I know where you usually initial I will know what it is and
who the initials belong to.

Tyra Norfleet, Financial Coordinator, AlignStaffing, RCN 301-289-8007

Thanks.

Fax All Documents RCN Accounting: 1-866-565-9307

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