HOPE INVOICE SUBMISSION
PLEASE INDICATE HOW YOU WOULD PREFER TO SEND YOUR INVOICE
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I want to upload my invoice that I generate. It includes all the needed information
I would like to use your template and fill in the invoice details
THERAPIST/ PRACTICE DETAILS
PROVIDER NAME
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First Name
Last Name
Credentials
PROVIDER EMAIL
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example@example.com
BILLING EMAIL, if different than provider's email.
example@example.com
CLIENT INFORMATION
Application Number
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CLIENT NAME
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First Name
Last Name
SERVICE DETAILS
* Session rate is the rate you charge the client before the copay is applied. Please note: if your client has a required co-pay the co-pay amount will be automatically deducted.
Please note, invoices may be shared with your client.
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Please upload the invoice here
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Accepted File Types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
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