Invoice Homecare Service Form – Fill Out and Use This PDF

The Invoice Homecare Service form serves as a crucial document for informal caregivers to detail the services provided to an insured person, including but not limited to caregiving dates, times, activities of daily living, and total charges for reimbursement. It requires detailed entry of service dates, times, approved charges, and proof of payment to streamline the caregiving reimbursement process. For a seamless experience in claiming your reimbursement, fill out the form by clicking the button below.

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Invoice Homecare Service Form PDF Details

In today's healthcare landscape, the role of informal caregivers has become increasingly recognized and valued, necessitating a systematic approach to reimbursement for homecare services provided. The Invoice Homecare Service form serves as a pivotal tool in this process, facilitating a structured and proof-based reimbursement methodology. It outlines a meticulous yet straightforward process where essential details such as the insured’s claim ID, names of both the insured and the informal caregiver, and specific service dates are captured. Detailed logging of service hours, including the start and end times, along with the approved hourly charge, enables the calculation of total hours worked and the corresponding payment amount. This form not only enumerates the activities of daily living services provided, distinguishing between direct assistance and indirect support tasks such as meal preparation versus eating assistance, but also sets clear guidelines for acceptable proof of payment, emphasizing the need for legitimate and verifiable financial transactions. Further enhancing its integrity, the form requires signatures from the informal caregiver, the insured, and, if applicable, a legal representative, underscoring the importance of accountability and mutual acknowledgment of the services rendered. Additionally, the form contains provisions to prevent fraudulent claims, by mandating handwritten signatures and if necessary, an attestation by a third party to verify the authenticity of the services claimed. It stands as a testament to the meticulous processes adopted by insurance entities and caregiver organizations to ensure fair and transparent dealings, supported by the Federal Long Term Care Insurance Program and regulated by the U.S. Office of Personnel Management.

Question	Answer
Form Name	Invoice Homecare Service Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	home care invoice, informal caregiver invoice, caregiver invoice template, federal program informal a004 form

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Informal Caregiver Invoice

Instructions

1.Enter the insured’s claim ID and name, as well as the informal caregiver’s name.

2.Enter one date of service per line.

3.Complete the time in and time out for that calendar day. Include a.m. and/or p.m., and round time to the nearest quarter hour.

4.Enter the total hours, approved hourly charge (per plan of care), and daily total for each date of service.

5.Enter the total reimbursement amount requested.

6.Mark an “X” in the correct box for each activity of daily living service provided per line.

ffPlease note: Eating refers to providing assistance with getting food into the insured’s mouth or assistance with a feeding tube or intravenous feeding. It does not mean providing assistance with meal preparation. Transferring means providing assistance with getting out of a bed, chair, or wheelchair. It does not mean providing transportation to the insured.

7.Enter the check or transaction number that corresponds with each date of service and attach the appropriate proof of payment. Accepted proof of payment includes:

Canceled personal, business, substitute, or cashier’s checks

The following is required:

ffimage of the front and back of the check ffbank name and routing number present on

the front of the check

ffvalid bank stamp (ink imprinted and/or electronic) ffsubstitute checks must also include a disclosure

statement indicating that the check is a legal copy of the original

Please note: We do not accept carbon copies or duplicate checks, copies of uncashed checks, or copies of check registers as proof of payment.

eStatements and online bill pay receipts The following is required:

ffbank name or logo ffpayee name ffremitter name ffposted or cleared date

ffcheck number (this does not apply to electronic funds transfers or wires)

ffpayment amount

ffcorresponding reduction in account balance (this does not apply to online bill pay receipt)

Money orders or payroll payments

ffIn all cases, payment must be made after services are rendered.

ffPayments made by cash or checks made out to cash are not reimbursable. ffThe invoice total and proof of payment amount must match.

8.The informal caregiver must sign and date the invoice after services are rendered.

9.The insured or the insured’s legal representative must sign and date the invoice after services are rendered.

10.If the informal caregiver and legal representative who sign the form on behalf of the insured are the same person, then an additional signature is required by a third-party to attest to the services rendered, hours worked, and payment made. Note: Handwritten signatures are required.

11.Visit LTCFEDS.com to download more invoices.

Please return your completed invoice and proof of payment by email to claimsinfo@ltcpartners.com, by fax to 1-866-513-2674, or by mail to Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-0797.

The Federal Long Term Care Insurance Program is sponsored by the U.S. Office of Personnel Management, insured by John Hancock Life & Health Insurance Company, and administered by Long Term Care Partners, LLC.

A004 v. 7 0919

Informal Caregiver Invoice

Claim ID

Insured’s name

First name

M.I.

Last name

Informal caregiver’s name

First name

M.I.

Last name

Informal caregiver’s relationship to the insured

Date

Time in

Time out

Total hours

Approved

Daily total

(mm/dd/yy)

(indicate a.m. or p.m.) (indicate a.m. or p.m.)

hourly charge

Description of services provided:

Total paid

Bathing

Dressing

Toileting

Supervision/safety

Amount to reimburse

Continence

Eating

Transferring

Other

Taxes included

Partial

Check or transaction numbers:

I have enclosed proof of payment (outlined on the back of this invoice).

Any person who knowingly and with intent to defraud any insurance company or other person ﬁles an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Sign and date after services are rendered.

Informal caregiver’s signature
	Date signed		/	/
(Required)		(Required: mm/dd/yy)
Insured’s or legal representative’s signature
	Date signed		/	/
(Required)		(Required: mm/dd/yy)
Additional signature
	Date signed		/	/
		(Required: mm/dd/yy)

If there is more than one legal representative that must act jointly, then all representatives must sign.

Invoice Homecare Service Form – Fill Out and Use This PDF

Invoice Homecare Service Form PDF Details

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