Aspire NJ Invoice Submission Form
This form is required for submission to payroll. Claims must be submitted by 11:59 PM on Monday to be considered for the pay date 14 days from that date of submission. Claims submitted after Monday deadline will be automatically rolled into the processing for the following Monday's submission. Only claims in which there are no duplicate claims, the original paperwork is mailed, and progress notes are uploaded into CYBER in the appropriate format will be honored.
Email address *
Submitters Name:
Your answer
Service Type *
In this next section, we require youth's first initial and last name, date of service, duration of service(in hours). Each youth will have their own line with total hours for that youth in this submission listed at the end. We will match the rest internally. DO NOT USE FULL NAMES. ex: D.Hunter: 5/4/19 - 3 Hours, 5/11/19 - 2.5 Hours Total Hours: 5.5 hours CLAIMS FOR SUBMISSION:
Your answer
Total Hours: *
Your answer
Total Amount Due: *
Your answer
Were you able to meet with each youth assigned to you during this pay period? *
Required
If you have not been able to meet with an assigned youth, please explain why in only one sentence.
Your answer
Do you have the capacity to accept more youth at this time? If yes, please state how many extra hours you are available. *
I herby certify that all progress reports associated with this submission have been properly documented and uploaded to CYBER *
I hereby certify under penalty of perjury that all claims and supporting documents provided in this submission are true and accurate representations of authorized service encounters that are free of fraud, waste, and abuse. *
Required
Electronically Signed: *
Your answer
Would you like a team member to reach out to you this week? *
Contracted Service Rate: *
Your answer
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