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Examination Invoice PDF Details

An invoice is a document that summarizes the products or services provided to a customer. It typically includes information such as the date, items purchased, and price. An examination invoice is specific type of invoice that is used for billing customers for medical services. This document can be used to submit claims to insurance companies, receive payments from patients, and track expenses. Examination invoices should contain all the relevant details of the medical procedure including the provider's name and contact information, service codes, and patient demographics. They should also include an itemized list of the services provided with corresponding prices. Here are some tips on creating an effective examination invoice: 1. Make sure all information is accurate and legible. 2.

You'll find it useful to understand the amount of time you will need to fill out this examination invoice and just how long this form is.

Question	Answer
Form Name	Examination Invoice
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	independent care provider form, invoice independent health care, invoice health care, genworth health care

12

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Invoice for Reimbursement for Medical Evidentiary Examination

for Victims of Sexual Assault Information and Instructions

Pursuant to Penal Code § 13823.95, law enforcement may seek reimbursement to offset the cost of conducting medical evidentiary examinations for victims of sexual assault.

Funding for these reimbursements comes from one of two sources of funds, depending on whether the victim, at the time of the examination, has determined to report the assault to law enforcement or is undecided whether to report the assault to law enforcement.

Cal OES will reimburse law enforcement to offset the cost of medical evidentiary examinations as follows:

•The actual cost of the examination up to $911 for victims that are undecided, at the time of an examination, whether to report the assault to law enforcement.

Examinations must have occurred on, or after, October 1, 2020.

Law enforcement may request reimbursement at this rate for the use of: o The Forensic Medical Report: Abbreviated Adult/Adolescent Sexual

Assault Examination (Cal OES 2-924), or

o The Forensic Medical Report: Acute Adult/Adolescent Sexual Assault Examination (Cal OES 2-923).

•The actual cost of the examination up to $1,127 for victims that have determined, at the time of the examination, to report the assault to law enforcement, to the extent funds are available.

Examinations must have occurred on, or after, July 1, 2021.

Law enforcement may request reimbursement at this rate for the use of: o The Forensic Medical Report: Acute Adult/Adolescent Sexual Assault

Examination (Cal OES 2-923),

o The Forensic Medical Report: Nonacute Child-Adolescent Sexual Abuse Examination (Cal OES 2-925), or

o The Forensic Medical Report: Acute Child-Adolescent Sexual Abuse Examination (Cal OES 2-930).

Complete all sections of the form and submit to VSB@caloes.ca.gov within six months of the medical evidentiary examination.

Cal OES 2-960 (Revised 10/2021)

Invoice for Reimbursement for Medical Evidentiary Examination

for Victims of Sexual Assault

Law Enforcement Agency: ___________________________________________________

Physical Address: ____________________________________________________________

Payment Mailing Address: ____________________________________________________

Exams for victims that are undecided, at the time of an examination, whether to report the assault to law enforcement.

				Reimbursement
	Date of	Case #	Actual Cost of	Requested (no
	Examination	Case #	Exam	more than $911
	Examination		Exam	more than $911
				per examination)





			Total Requested	$ 0.00

Exams for victims that have determined, at the time of the examination, to report the assault to law enforcement. This includes examinations for all children under the age of 12.

Date of

Examination

Case #

Actual Cost of

Exam

Reimbursement Requested (no more than $1,127 per examination)

Total Requested

$ 0.00

By submitting this form I certify to the best of my knowledge and belief that the information on the invoice is true, complete, and accurate. I am aware that any false, fictious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims, or otherwise.

Submitted By: _______________________________________________________________

Telephone: ________________ Email: _________________________________________

Cal OES 2-960 (Revised 10/2021)

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In the Invoice for Reimbursement for, Law Enforcement Agency, Physical Address, Payment Mailing Address, Exams for victims that are, Date of Examination, Case, Actual Cost of Exam, Reimbursement Requested no more, Exams for victims that have, and Total Requested part, focus on the significant particulars.

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The Reimbursement Requested no more, Total Requested, By submitting this form I certify, Submitted By, Telephone Email, and Cal OES Revised section will be the place to put the rights and obligations of both sides.

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