Attachment 2 - Invoice Template (Primary Program) and Invoice Template (Pilot Program)

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Overview

Read Me and Print Me First
Invoice Template

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Sheet 1: Read Me and Print Me First

For your convenience, here are a few hints for using the RHCD Invoice template:
1. Save this file on a drive that you access on a regular basis (so you have a clean invoice template for next
month's invoice).
2. Using the "Save As" feature, save this file again with a name of your choice that is
appropriate for the invoice you are about to complete.
3. Enter information in the shaded areas only. The information required is found on the
Support Schedule received from RHCD (with the exception of Service Prodiver Invoice Number -
you assign this number).
4. If entering more than 20 line items, find additional invoice pages below page 1.
5. After all line items have been entered, verify the Total Invoice Amount located in the top section of the invoice.
6. To avoid printing blank invoice pages, specify the pages you have used in the Print Pages fields.
7. After printing, date, sign, print your name and phone number on the bottom of page 1.
8. Send the invoice to:
		RHCD
		80 South Jefferson Road
		Whippany, NJ 07981
9. If you have any questions, please contact Karen Mogensen at 973-581-6756 (e-mail: [email protected]).

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Sheet 2: Invoice Template

RHCD SERVICE PROVIDER INVOICE
					FOR RHCD USE ONLY
					Header Verification
Service Provider Name					____	RHCD Processed Date
SPIN					____	Number of Records
Service Provider Invoice Number					____	Number of Records Approved
Invoice Date to RHCD (mm/dd/yy)					____	RHCD Approved Total Amount
Total Invoice Amount			$0.00		____
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		Code
1									____
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20									____
I certify that the information contained in this invoice is correct and that the health care providers and Billing Account Numbers listed above have been credited with the amount shown under "Support Amount to be Paid by USAC".
Signature:						Date:
Print Name:						Telephone # :
RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
21									____
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45									____
RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
46									____
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69									____
70									____
RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
71									____
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95									____
RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
96									____
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