Mental Wellness Center Work Invoice
This is the form required for payroll submission. Invoices must be submitted by 11:59PM on any given Sunday to be considered for the pay date 14 days from that date of submission. In order to have a claim paid, the original paperwork must be received, progress notes and treatment plans must be uploaded in CYBER in the appropriate format. Please fill out an invoice for every service provided, i.e. BA, IIC, Advocacy etc.

Mental Wellness Center LLC/www.wellnesscenter.center
*Required
Name *
Your answer
Work Region *
Hourly Rate *
Your answer
Service Provided *
Please provide the youth's first and last initials, dates of service, and duration of service (in hours). Each youth should have their own line with total hours listed at the end, i.e. S.M.: 1/2/19-2.0 hours, 1/3/19-1.5 hours: Total 3.5 hours *
Your answer
Total Hours for Invoice *
Your answer
Total Amount Due *
Your answer
Today's Date *
MM
/
DD
/
YYYY
Validation: By typing my name below, I hereby certify that all progress reports, all claims, and supporting documents associated with this submission have been properly documented and uploaded onto the appropriate systems and are free of fraud. *
Required
Electronically Signed *
Your answer
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