HPCI Residence Invoice Request
Name of person requesting invoice
*
Business Contact Email (Submitter)
*
example@example.com
Client Information
Patient Name
*
First Name
Last Name
Billing Contact Name
*
First Name
Last Name
Billing Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Contact Phone Number
Please enter a valid phone number.
Client Contact (Recipient)
*
example@example.com
Invoice Information
Date of Invoice / Date of Residence Admission
*
-
Month
-
Day
Year
Date
Siegenthaler Center Billing Rules:
By Default - Every new patient admitted to the Residence will be billed for the remaining number of days in the billing week. Billing weeks run from Monday - Sunday. Date arrival: $295 x # of days until Sunday = amount of 1st invoice. On every Monday thereafter they will be billed for 7 days or $2,065 until termination or exit.
Do you want someone from your team to be copied (CC) on invoice?
*
Yes
No
Name of person who you would like to be copied in invoice, if applicable.
Email Address of person
example@example.com
Additional Comments:
Submit
Should be Empty: