Empower U. Invoice Submission Form
This is the form is required for submission to payroll. Claims must be submitted by 11:59PM on any given Monday to be considered for the pay date 14 days from that date of submission. Claims submitted after the 11:59PM Monday deadline will be automatically rolled into the processing for the following Monday's submission window. Only claims in which there no duplicate claims, the original paperwork is mailed in, and progress notes are uploaded in CYBER in the appropriate SOAP format will be honored.

EACH LINE OF SERVICE (RESPITE, BA, IIC, ETC.) GETS IN OWN SEPARATE SUBMISSION.
Submitter Name *
Your answer
Program Partner *
This is the individual who serves as your primary support partner for you region or team or the service you are providing.
Service Type *
Contracted Service Rate for this Service *
Your answer
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 *
Your answer
Total Hours *
Please enter ONLY the numeric portion of your hours (ex. 48)
Your answer
Total Amount Due *
Your answer
Were you able to meet each youth assigned to you this pay period? *
We just want to be ahead of any potential service related concerns. If you have not been able to meet with each child assigned to you, please tell us who (initials) and why (one sentence). *
Your answer
Do you have capacity to accept more youth at this time? (If yes, selection "other" and type in how many extra hours you are available for weekly) *
I hereby certify that all progress reports associated with this submission have been properly documented and uploaded onto the appropriate systems. *
Required
I hereby agree to mail original service encounter paperwork to Empower U within 3 days of this submission. *
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: *
Your answer
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