Attachment 5 - Interpreter Billing Document revised 2.3.20.xlsx
XLSX spreadsheet 52 KB Posted
- Attached to
- Interpreting & Translation Services
- Solicitation number
- 103325-O3
- Issued by
- Blaine County, Nebraska
About this file
This document is an Interpreter Billing Document related to a contract opportunity for the Nebraska Department of Health and Human Services (DHHS). The document outlines the process for interpreters to submit invoices for interpreting and translation services provided to DHHS clients. It includes fields for the interpreter's name and language, DHHS staff information, client information, date and duration of service, and the calculation of the payment amount based on the service type and duration. The document also includes instructions for submitting the completed billing document to the DHHS Interpreter Billing email address and notes that DHHS reserves the right to not pay any initial request for payment submitted later than 60 calendar days past the last day of the month for which services were provided.
The related state and local contract opportunity is for prequalifying a pool of Contractors to provide interpreting and translation services for DHHS. The services may include translation and/or interpretation for or on behalf of DHHS program clients and/or providers. No further details on the pricing terms, set asides, incumbents, funding requirements, or other salient information are provided in the document.
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Text version
Sheet1
| Department of Health and Human Services | Date: | ||
| ATTACHMENT 5 | |||
| INTERPRETER BILLING DOCUMENT | Interpreter Name: |
| Interpreter Language: | ||
| DHHS Staff Name or Authorized Representative: | ||
| DHHS Office Location: | ||
| Interpreter Street Address: |
| DHHS Staff Name or Auth Rep Phone Number: | |
| DHHS Division: | |
| Interpreter Phone Number: |
| CASE INFORMATION | |
| Client Name: | |
| Client Street Address: |
Phone Number:
Client ID Number: Client Phone Number:
| DATE | SERVICE DELIVERY TIME | ||
| START | FINISH | **SUB-TOTAL HOURS |
Cancellation Fee (if applicable)
| In Person: Total Service Hours | |
| In Person: Amount to be paid | $ |
| Phone: Total Minutes |
Phone: Amount to be paid $ Latifa Elbergame: Latifa Elbergame:
How this amount was calculated:
$1.40 * 30min = $42.00
43 min - 30min = 13min We round the 13min to the nearest 15min $40.00 * 0.25 (15min) =$10.00
$42.00+$10.00=$52.00
Translation: Total Hours
| Translation: Amount to be paid | $ | ||
| Total Hour Payment: | $ | Total Invoice Payment Amount | $ |
| Statement: | Provider's Signature | Date of Signature |
| 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 Printed Name | Provider's Phone Number |
| Instructions: | Approving Worker's Signature | 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).
Approving Worker's Printed Name and Division Worker's Phone Number
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.
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File details come from the government source that posted it. Updated .