Clone of Voucher Invoice Submission

Thank you for your support and serving our community in Washington State!

WA Therapy Fund Foundation has provided 20 vouchers to support Black folx in the community at a maximum of $200.00 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 20 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.

YOU WILL RECEIVE AN EMAIL CONFIRMING THAT THE TRANSACTION HAS BEEN PROCESSED.

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!

The name and photo associated with your Google account will be recorded when you upload files and submit this form.

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 Name

First NameLast Name

Provider Email

example@example.com

Provider Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Does your client live or attend school in Seattle? If NO STOP Here! Use our other invoice form

Service delivery method

Does the client have insurance?

Use approved rates only. The standard Therapy Fund rate for DEEL clients is up to $200 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

What is your individual hourly rate?

Amount to be paid ( up to $200 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.

Signature

Date signed

Date

DEEL Youth Therapy Invoices Submission

Provider Information

Services

Voucher & Payment Information

Certifications