Voucher Program

Voucher Program Receipt
You will be required to provide your Provider ID and all Voucher Numbers correctly in this form. You will also be required to verify your level of service provided. All submissions will be reviewed for reimbursement. Any errors in completing this form will result in delays in reimbursement and will, in most cases, require you as the provider to resubmit all attached vouchers and invoices.
Provider Name *
Please enter your agency's Invoice Number *
Please enter the invoice date for this voucher.

Month Day Year
If invoice has not been submitted then please enter the anticipated invoice date.
Enter Voucher Number *
Voucher number must be an exact match to the Voucher being invoiced. Errors will result in delayed or denied reimbursement.
# of Services Being Invoiced *
Specify number of services being submitted for this Voucher for this invoice only.
1. Service Provided *
1. Provider Classification *
1. Number of Units Provided *
1. Date of Service *

Month Day Year
1. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
2. Service Provided *
2. Provider Classification *
2. Number of Units Provided *
2. Date *

Month Day Year
2. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
3. Service Provided *
3. Provider Classification *
3. Number of Units Provided *
3. Date *

Month Day Year
3. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
4. Service Provided *
4. Provider Classification *
4. Number of Units Provided *
4. Date *

Month Day Year
4. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
5. Service Provided *
5. Provider Classification *
5. Number of Units Provided *
5. Date *

Month Day Year
5. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
6. Service Provided *
6. Provider Classification *
6. Number of Units Provided *
6. Date *

Month Day Year
6. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
7. Service Provided *
7. Provider Classification *
7. Number of Units Provided *
7. Date *

Month Day Year
7. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
8. Service Provided *
8. Provider Classification *
8. Number of Units Provided *
8. Date *

Month Day Year
8. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
9. Service Provided *
9. Provider Classification *
9. Number of Units Provided *
9. Date *

Month Day Year
9. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
10. Service Provided *
10. Provider Classification *
10. Number of Units Provided *
10. Date *

Month Day Year
10. Reimbursement Rate for this Service
Check this box if any data collection funds were used to incentivize patient participation.
Voucher Total
Please read and attest to the following. *

I declare and affirm under the penalties of perjury that this claim has been examined by me, and to the best of my knowledge and belief, is in all things true and correct.
Review Name: *
Receipt Submission Date: *

Month Day Year
Email
Enter your email if you would like to receive an email copy of this form
Sage Approver
Sage Approved Date

Month Day Year
Date
Should be Empty:

Voucher Program Receipt