Cost Breakdown
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COUNSELOR / PEER / PRP NAME
PAY PERIOD
NUMBER ON CASE LOAD
CASE LOAD CONSUMER TOTAL NUMBER
CASE LOAD CONSUMER (CONTINUED) NUMBER
DESCRIPTION - For the payment
Cost
REQ / Load
QTY Turned In
Total Cost
Read Carefully
CLINICIAL REQ - COPY OF ALL DOCUMENTATION.
NO DOCUMENTATION SUBMITTED. NO PAY.
ALL DELIVERABLES DUE TO PW BY WED AT 12. ANYTHING SUBMITTED AFTERWARDS WILL DELAY PAYMENT.
100% BOOKS ARE TO BE INVENTORIED AND QC FOR EACH PAY PERIOD FOR COMPLETENESS.
NEW FORMS WILL BE ADDED AFTER DELIVERABLES CHECKED
CONSUMERS Seen During Pay Period
CONSUMERS NOT Seen During Pay Period
REFERRALS DONE During Pay Period
C NUMBER
REFERRAL TYPE
ORGANIZATION CONTACT
REFERRAL STATUS
For more information,
OOH Training Department : 443.805.8927
OOH Main Office 1.855.9. OOHHOPE (1.855.966.4467)
PW@OrganiationOfHope.org
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