Invoice Homecare Service Form – Fill Out and Use This PDF

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:

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.

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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.