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 NameDate of ServiceService TypeCOMMENTS: Type of Consultation for example: ADCS Staffing, Court Testimony, Telephone Consult (as applicable)Billed UnitsUnit RateTotal Due
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total:0.000.00

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.

NameService Unit of Measure
CNSLG-ASSESSREPORT
CNSLG-ASSESS RUREPORT
CNSLG-CONSULTHOURS
CNSLG-CONSULTRUHOURS
CNSLG-GRP HOURPERSON
CNSLG-GRP HR RUPERSON
CNSLG-HOME BASEHOURS
CNSLG-HOMEBS RUHOURS
CNSLG-IND-HRHOURS
CNSLG-IND-HR RUHOURS
CNSLG-UNT CNSLTHOURS
CNSLG-UNTCNS RUHOURS

image1.jpg

File details come from the government source that posted it. Updated .