Attach D_DSS Form 3797.pdf
PDF 131 KB Posted
- Attached to
- APS - ETPS - HOMEMAKER - CNAS -PCAS
- Solicitation number
- 5400029952
- Issued by
- Richland County, South Carolina
About this file
This is a Social Services Block Grant Purchase of Service Invoice form (DSS Form 3797, revised 3/23/26) used by the South Carolina Department of Social Services for reimbursement submissions by service providers. The form is designed for providers delivering services under contracts related to Adult Protective Services (APS), Elder Targeted Protective Services (ETPS), Homemaker services, Certified Nursing Assistants (CNAs), and Personal Care Assistants (PCAs). Providers must complete the invoice with their contract information from Schedule B, including provider name, contract number, provider address, contract period, and invoice period dates. The form accommodates multiple service elements and county-based service delivery tracking, with providers required to document the number of clients served, units of service provided, applicable unit rates, and corresponding dollar amounts for each billing period.
The invoice requires detailed documentation of service delivery metrics, including current month units and clients served multiplied by contracted unit rates to calculate reimbursable dollars. Providers may also record adjustments to prior month invoices, using brackets to denote funds owed back to the South Carolina Department of Social Services for erroneously billed units. The form mandates certification by an authorized individual confirming the accuracy of billing data, verification that services are properly documented and authorized, and assurance that no duplicate reimbursement from other federal or state funding sources has been sought. Completed invoices must be mailed to the address specified in the reimbursement section of the provider's contract, with submission requiring the provider's signature, title, telephone number, and date.
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Other files
| File | Type | Posted |
|---|---|---|
| Solicitation.docx | DOCX document | |
| Attach C_ DSS Form 1580.pdf | ||
| Attach B_DSS Form 30141.pdf | ||
| Attach A_ DSS Form 2433.pdf |
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Text version
DSS Form 3797 (3/23/26)
SOCIAL SERVICES BLOCK GRANT PURCHASE OF SERVICE INVOICE
Provider Name: Contract Number:
Provider Address: Provider Code: Service Code:
Contract Period Invoice Period:
From:
County Code:
Current Month
Current Month
Dollars
Unit Rate: $
Dollars
Totals
Unit Rate: $
County Code:
I certify that I have reviewed this invoice; that the invoice has been prepared from the books and records of the agency named within; that the invoice is true and correct to the best of my knowledge and belief; that no other request for reimbursement from other federal and/or state funds has been made nor has any other reimbursement been received, applied for, nor will they be applied for, for these expenditures; and that the agency has on file proper client authorizations for these services and the necessary documentation to support these expenditures.
Title:Preparer’s Signature:
Title:
Telephone:
Date:Provider’s Signature:
Total Due $
Adjustment for Prior Month of
Adjustment for Prior Month of
Totals
County Code:
Unit Rate: $ Current Month
Adjustment for Prior Month of
Totals
Clients Served
Units Served
County Code:
Unit Rate: $
DollarsUnits Served
Clients Served
Current Month
Adjustment for Prior Month of
Units Served
Clients Served
County Code:
Unit Rate: $ Current Month
Adjustment for Prior Month of
Totals
DollarsUnits Served
Clients Served
Clients Served
Units Served Dollars County Code:
Unit Rate: $
Totals
Adjustment for Prior Month of
Current Month
Totals
Clients Served
Units Served Dollars
To:
DSS Form 3797 (3/23/26) PAGE 2
INSTRUCTIONS FOR DSS FORM 3797
Step 1: Complete the following general information
1. Provider Name – As shown in Schedule B of your contract.
2. Contract Number – As shown in Schedule B of your contract.
3. Provider Address – As shown in Schedule B of your contract.
4. Contract Period – As shown in Schedule B of your contract.
5. Invoice Period – The invoice period must be within the contract period.
6. Provider Code – Last five digits of contractor code shown in Schedule B of your contract.
7. Service Code – First four digits of contractor code shown in Schedule B of your contract.
Step 2: Complete the following information related to service delivery and dollars
The following must be completed for each service element shown in Schedule B of your contract:
1. County Code – Enter the county code where services were rendered only if your contract breaks out services by county in Schedule B.
2. Unit Rate – Enter the unit rate as shown in Schedule B of your contract.
3. Current Month – Enter the number of clients and the number of units served during the current reimbursement period. Multiply the units served by the unit rate and enter the result in the DOLLARS column. Round dollars to the nearest whole dollar.
4. Adjustment for Prior Month of – This line is used to make adjustments to prior month invoices. Record the month of service the adjustment affects (i.e. Prior month of 10/99). If the adjustment is for units which you have not previously billed, record the units and dollars due your agency. If the adjustment is for units previously billed in error, record the units and dollars using brackets to denote funds due back to SCDSS.
Step 3: Total Due: Record total amount due. Amount must be in whole dollars.
Step 4: Please read the certification statement before signing the invoice. If someone other than an authorized individual prepares the invoice, have the preparer sign the form. Record your current telephone number in case there are any questions pertaining to this invoice.
Step 5: Review the form for accuracy and legibility and mail the signed original to the address stated in the reimbursement section of your contract.
For further information or assistance regarding this form, please contact the South Carolina Department of Social Services.
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