Provider Claim Form

Data Elements: ProviderClaimForm.aspx

General Information

Name:
Phone:
E-mail Address:
Services for the month of:
Mental Health Provider:
Group date, time, and location:

Participants

Participant Name Date of Attendance Date of Attendance Date of Attendance Date of Attendance Date of Attendance Date of Attendance Date of Attendance

Number of clients seen:

Claims

# Members/Clients/Groups Total
Claim for Groups ($100.00) $0
Claim for assessments ($80.00) $0
Claim for Individual ($65.00) $0
Claim for Family Group ($100.00) $0
Claim for Family Individual ($65.00) $0
Claim for Presentation(s) ($100/hr): hours $0
Final Total: $0
Presentation description (number in attendance):  

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