2-Appendix AA FFS CoverSheet.pdf

This is a Fee for Service Invoice Cover Sheet template for Delaware County Department of Human Services, designed for use with the Standard Appendices documentation framework. The form serves as a billing document for service providers contracted with Delaware County DHS to invoice for services rendered under fee-for-service arrangements. The cover sheet includes designated fields for service or level of care categories, with corresponding columns for total units provided, applicable rates, and calculated service or program expenses, culminating in a total invoice amount. The document requires completion of provider identification information including the provider name and location, the service month for which billing applies, the program name being billed under, and a unique invoice reference number assigned by the Delaware County DHS Program Office. Authorization is required through an authorized signature and date field to validate the invoice submission.

The form structure supports the performance-based contracting framework that Delaware County seeks to establish through its evaluation services contract with an academic or research institution. This template facilitates the collection of standardized billing data necessary for program impact evaluation and contracting analysis, allowing for systematic tracking of service utilization, unit rates, and cost data across Delaware County's non-residential youth prevention, diversion, and intervention services. The blank line items and flexible format accommodate various service categories and levels of care, enabling comprehensive documentation of invoiced services regardless of program type or service delivery model.