Attachment 5 - Interpreter Billing Document revised 2.3.20.pdf

Total Hour Payment: $

Translation: Total Hours

Phone: Total Minutes

START FINISH **SUB-TOTAL HOURS

In Person: Total Service Hours

In Person: Amount to be paid $

Cancellation Fee (if applicable)

Approving Worker's Printed Name and Division

Provider's Printed Name Provider's Phone Number

Date of Signature

Approving Worker's Signature

Total Invoice Payment Amount $

The completed billing document should be submitted to the DHHS Interpreter Billing Email Address at: dhhs.interpreterbilling@nebraska.gov.

DHHS reserves the right to not pay any initial request for payment that is submitted later than sixty (60) calendar days past the last day of the month for which services were provided.

Instructions: Date of Signature

*Please identify whether the interpreting included in-person, over phone, and/or translation services.

**Please round total service hours to the nearest quarter hour except where not allowed per contract (medicaid funds and/or over phone).

Worker's Phone Number

Statement:

By signing this form, the signor certifies that the information contained in this document is true, complete and accurate, and in compliance with the terms of the contract. Anyone filing a false claim may be prosecuted for fraud.

Provider's Signature

$Phone: Amount to be paid

Translation: Amount to be paid $

Date:

ATTACHMENT 5

INTERPRETER BILLING DOCUMENT

Department of Health and Human Services

Interpreter Language:

Interpreter Name:

Interpreter Phone Number:

Interpreter Street Address:

DATE

DHHS Staff Name or Authorized Representative:

DHHS Staff Name or Auth Rep Phone Number:

DHHS Office Location:

DHHS Division:

CASE INFORMATION

Client Name: Client Street Address:

Client ID Number:

Client Phone Number:

SERVICE DELIVERY TIME