Your email
*
example@example.com
Support Provider Full Name
*
Enter your name or the names of the support team member for the period related to the participants session/s.
Participant name/s
*
If delivering a group session with multiple participants please enter first names with commas.
Type of support provided
Please Select
Online session
Face-to-face without travel
Face-to-face with travel
Travel method
*
Please Select
Motor Vehicle (own)
Motor Vehicle (shared)
Public Transport
Push Bike
E-Bike
Walking
Not applicable
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Finish Time
*
Hour Minutes
AM
PM
AM/PM Option
Support Delivery Start Date
*
-
Year
-
Month
Day
Date support started
Support Delivery End Date
*
-
Year
-
Month
Day
Date support ended
Support Notes
*
Please include day of the week, dates, start / finish times what you did, where you went & how the supports helped the participants goals.
Claim Reference Number
*
Please use the participants initials followed by your initials & the date of supports. Eg YNPN220222. For group sessions please use your initials & a capital G followed by the date of supports. Eg YNG220222.
Service Description
*
Please Select
Assessment Recommendation Therapy or Training - Psychologist: 15_054_0128_1_3
Assessment Recommendation Therapy or Training - Counsellor: 15_043_0128_1_3
Assessment Recommendation Therapy or Training - Physiotherapist: 15_055_0128_1_3
Assessment Recommendation Therapy or Training - Dietitian: 15_062_0128_3_3
Assessment Recommendation Therapy or Training - Exercise Physiologist: 15_200_0126_1_3
Assessment Recommendation Therapy or Training - Exercise Physiologist: 15_200_0128_1_3
Assessment Recommendation Therapy or Training - Occupational Therapist: 15_617_0128_1_3
Assessment Recommendation Therapy or Training - Other Professional: 15_056_0128_1_3
Employment Related Assessment And Counselling 10_011_0128_5_3
Quantity of Support Hrs
*
Please write these to 2 decimal places. eg 2hrs 30mins would be 2.5hrs, 2hrs 45mins would be 2.75hrs please calculate to the nearest 0.25hrs and include your reporting time.
Travel time
*
Please Select
0.0
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0.55
0.6
0.65
0.7
0.75
0.80
0.85
0.90
0.95
1
We pay travel time to the participant and from participant to another participant and home from last participant of the day to a maximum of 0.5hrs in a given journey unless otherwise specified. Leave blank for online sessions.
Hourly Amount
*
Please see relevant fees per hour above.
Travel Hourly Amount (50% of listed therapy amounts)
*
Please note this is see relevant fees per hour above.
Starting Vehicle Odometer reading
End Vehicle Odometer Kilometres Reading - upon direct return to usual business address from last participant or vehicle odometer reading prior to departure from client.
Kilometers
We can Bill & Pay Kilometers traveled to and from the participant & whilst with the participant unless otherwise specified in writing.
Kilometres Line item : 01_799_0117_8_1 | 04_799_0125_6_1 | 15_799_0117_1_3
We can Bill & Pay Kilometers traveled to and from the participant & whilst with the participant unless otherwise specified in writing.
Additional Expenses
Please provide receipts for parking & tolls.
Session total earnings calculation
*
Example: Support Hrs + 0.5hrs travel x Hourly Rate + Kms x 0.99cents + Additional expenses = Session Total Earnings x 0.75 (75%) Provider Partners please include processing fees) = Invoice total
Tax Invoice total
*
Your valid ABN
*
Please use the ABN you have been screened with
Please upload additional expenses receipts, photos of participant recepits for purchases, photos, cancellation evidence if any & any travel verification evidence details (eg start & finish vehicle odometer photos)
Browse Files
Drag and drop files here
Choose a file
Please add screenshot or photo of receipts for us to pay additional expenses.
Cancel
of
Submit
Should be Empty: