Voucher Invoice Submission

Free Therapy Fund Voucher Invoice Submission
Thank you for your support and serving our community in Washington State!
WA Therapy Fund Foundation has provided 8 vouchers to support Black folx in the community at a maximum of $130.00 per session. (We are working to secure more funding for couples sessions)

Providers must be licensed in Washington state. Use this form to submit requests for payment of an invoice (one voucher per form).

You can also wait and bill all 8 VOUCHERS at the end. You still will need to put dates of service and upload an actual invoice at the end.

YOUR REQUEST WILL BE PROCESSED WITHIN 30 BUSINESS DAYS excluding Holidays.

A receipt/invoice must be included with each request for payment.

This form is mobile friendly and makes submitting receipts for reimbursement easy when using a mobile device. Simply upload a photo of the receipt from your cell phone/ipad, etc.., no scanning necessary!

Any files that are uploaded will not be shared outside of WA Therapy Fund Foundation.

Payments will only be processed via paypal, ACH, or a secure HIPAA compliant payment source such as square where you would provide a link below for payment. Please review your provider agreement section under "compensation".
Provider Information
Provider Name

First NameLast Name
Provider Email
example@example.com
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Services
Service delivery method
Does the client have insurance?
Voucher & Payment Information
Use only approved rates. The standard Therapy Fund rate is up to $130 per counseling hour unless Therapy Fund Foundation has provided written authorization.
Voucher number(s)
Enter multiple voucher numbers as a range or list (e.g., 1–8 or 1, 2, 3, 4).
Date of Service Client was seen

MonthDayYear
2 digit month, 2 digit day, 4 digit year
What is your individual hourly rate?
Amount to be paid ( up to $130 per voucher)
How would you like to receive your payment?
Please fill out this information so we can set up your ACH profile
PayPal Account email for payment, or link to your site where we can make a payment with a debit card. Like square. If it requires login, our volunteers can not process. (If you do not have either we can NOT make payments to you!)
Please provide your link here
Upload Invoice (THAT INCLUDES VOUCHER #, Client name, and date of service) Nothing else is needed. Your client signed a waiver for privacy when signing up to allow their name to be included on billing invoices.

Your client signed a waiver for privacy when signing up to allow their name to be included on billing invoices.
Cancelof
Certifications
I certify under penalty of perjury that...

..the information provided in this invoice is true and accurate; that the services listed were provided as stated; that these services have not been billed to insurance or paid by another source; that the amount charged to Therapy Fund Foundation is consistent with or less than my ordinary rate and does not exceed the approved voucher rate; and that I am authorized to submit this invoice. I understand that incomplete or inaccurate submissions may delay payment.
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Free Therapy Fund Voucher Invoice Submission

Provider Information

Services

Voucher & Payment Information

Certifications