Empower U. Invoice Submission Form
IF YOU ARE PROVIDING DIRECT CARE SERVICES SUCH AS IIC, BA, MENTORING, OR ABA SERVICES, THIS FORM IS NO LONGER BEING CONSIDERED. IN ORDER TO SUBMIT INVOICES, THEY NEED TO COME THROUGH THE QUICKBASE APP. THANK YOU. PLEASE LOG INTO WWW.QUICKBASE.COM
Submitter Name *
Service Type *
Contracted Service Rate for this Service *
In this next section, we simply require the youth's first initial and last, dates 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 IN SUBMITTING.
Ex. "M. Gray: 4/20/16 - 3 hours, 4/17/16 - 1.5 hours | Total: 4.5 hours
S. Diaz: 4/15/16 - 1 hour, 4/4/16 - 1 hour | Total: 2 hours"
Claims for this Submission *
Total Hours *
Please enter ONLY the numeric portion of your hours (ex. 48)
Total Amount Due *
I hereby certify that all progress reports associated with this submission have been properly documented and uploaded onto the appropriate systems. *
Required
I understand that failure to update all progress reports, submit all original paperwork, and comply with treatment plan requirements will delay processing and payment of my claims. *
Required
I hereby certify under penalty of perjury that all claims and supporting documentation provided in this submission are true and accurate representations of authorized service encounters that are free of fraud, waste, and abuse. *
Required
Electronically Signed: *
Submit
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