Exhibit D DCS Counseling Consultation Services Invoice.xlsx
XLSX spreadsheet 26 KB Posted
- Attached to
- Master Agreement AZ|CTR064216
- Contract number
- CTR064216
- Issued by
- Arizona
About this file
This document is an invoice template for the Department of Child Safety (DCS) Counseling Consultation Services, specifically designed for behavioral health service providers. The document appears to be an official state government invoice form used by contractors providing counseling and consultation services to the child welfare agency, with a focus on standardizing billing and service documentation processes.
The invoice template outlines multiple service types including assessment reports, group counseling, home-based services, individual counseling, and consultation hours. Each service type has specific units of measure and rates, which are to be filled in by the service provider according to their contract. The form requires detailed documentation including participant ID, client name, date of service, service type, billed units, and unit rate. Providers must certify the invoice's accuracy and compliance with non-discrimination requirements, and the document includes guidance for electronic completion to ensure precise billing and record-keeping for child safety consultation services.
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Text version
Invoice
| EXHIBIT D |
| DEPARTMENT OF CHILD SAFETYCOUNSELING CONSULTATION SERVICES INVOICE |
| Provider Name: | Invoice #: | Original Invoice: |
| Provider ID #: | Page #: (example: 1 of 5) | Amended Invoice: |
| Contact Phone #: | Service Month/Year: | |
| Date Submitted: | ||
| Contract Number: | ||
| Region: | ||
| Provider Signature: | ||
| DATE: | ||
| “This invoice is a true and accurate account of the services listed on this statement for the time period specified; this invoice constitutes the full and complete charge for the services described above; that no further invoices | ||
| for payment of these services will be made; these services have been provided without discrimination based on age, race, color, creed, gender, religion or national origin and that this statement is subject to | ||
| federal and state audit review.” |
| Participant ID # | Client Name | Date of Service | Service Type | COMMENTS: Type of Consultation for example: ADCS Staffing, Court Testimony, Telephone Consult (as applicable) | Billed Units | Unit Rate | Total Due |
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| 0.00 | |||||||
| Total: | 0.00 | 0.00 |
Invoice User Guide
| EXHIBIT D |
| DEPARTMENT OF CHILD SAFETY COUNSELING CONSULTATION SERVICES INVOICE |
Counseling Consultation Services Invoice User Notes
This guide is intended to provide some useful tips in using the standard Behavioral Health Counseling and Consultation Services Invoice. Please note throughout that the cells have a summary of the information being requested to help describe required information. The following information provides quick tips to help you navigate the tool.
| Tab 1 – Invoice |
| · This tab is the summary of services by service type and includes Participant name, PID, dates of service, # of billed units, and the billed rate. Please fill out this template electronically. Do not handwrite. |
| · Please fill out the information requested in Rows 1 – 8. |
| · Please indicate if the invoice is an Original or Amendment by marking the appropriate line. Any change to an original invoice is considered an amended invoice. |
| · Row 3/Column F: Provider Invoice Number is a number you must fill in with your agency specific invoice number that you assign to this payment request. |
| · Please enter the rates specific to the various service types as outlined in your contract. |
| · Please check the formulas to ensure that the totals are calculated and summed accurately. |
&8Revised 6-30-15
Serv Types
| EXHIBIT D | |
| DEPARTMENT OF CHILD SAFETY COUNSELING CONSULTATION SERVICES INVOICE | |
| Note: | Please verify Contract for approved Service Types |
| Services types claimed will NOT be paid if not contractually approved. |
Please insert lines as needed on Invoice.
| Name | Service Unit of Measure |
| CNSLG-ASSESS | REPORT |
| CNSLG-ASSESS RU | REPORT |
| CNSLG-CONSULT | HOURS |
| CNSLG-CONSULTRU | HOURS |
| CNSLG-GRP HOUR | PERSON |
| CNSLG-GRP HR RU | PERSON |
| CNSLG-HOME BASE | HOURS |
| CNSLG-HOMEBS RU | HOURS |
| CNSLG-IND-HR | HOURS |
| CNSLG-IND-HR RU | HOURS |
| CNSLG-UNT CNSLT | HOURS |
| CNSLG-UNTCNS RU | HOURS |
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File details come from the government source that posted it. Updated .