Exhibit D DCS Counseling Consultation Services Invoice.xlsx
XLSX spreadsheet 26 KB Posted
- Attached to
- Master Agreement AZ|CTR064201
- Contract number
- CTR064201
- Issued by
- Arizona
About this file
This document is an invoice template for the Department of Child Safety (DCS) Counseling Consultation Services, designed for behavioral health providers to submit service claims. The document appears to be specifically tailored for the state of Arizona, with a focus on documenting counseling and consultation services provided to clients, likely in child welfare or related social services contexts.
The invoice template outlines multiple service types, including assessment reports, consultation hours, group counseling, home-based services, and individual counseling hours. Each service type has a specific unit of measure and is expected to be billed with corresponding rates as defined in the provider's contract. The document provides guidance for completing the invoice electronically, emphasizing accurate documentation of participant details, dates of service, billed units, and total compensation. Providers are required to certify the invoice's accuracy and attest that services were provided without discrimination, with the understanding that the invoice is subject to federal and state audit review.
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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 .