Voucher Program - Receipt (FY24)

Child Care Provider 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 receipts.
Receipt Details
Agency Name*
Agency's Invoice Number*
Invoice date for this voucher.

MonthDayYear
If invoice has not been submitted then please enter the anticipated invoice date.
Voucher Details
Enter Voucher Number*
Voucher number must be an exact match to the Voucher being receipted. Errors will result in delayed or denied reimbursement.
Name of Primary Service Provider*

First NameLast Name
# of Services Being Receipted*
Specify number of services invoiced for only this receipt.
Services Details
Please note that there can only be one Intake/Initial Apt. per Voucher Number. Intake/Intial Apts. should be entered in Service #1 when applicable.
Service #1
1. Date of Service*

MonthDayYear
1. Service Provided*
1. Provider Classification*
1. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
1. Total for this Service
Service #2
2. Date*

MonthDayYear
2. Service Provided*
2. Provider Classification*
2. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
2. Total for this Service
Service #3
3. Date*

MonthDayYear
3. Service Provided*
3. Provider Classification*
3. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
3. Total for this Service
Service #4
4. Date*

MonthDayYear
4. Service Provided*
4. Provider Classification*
4. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
4. Total for this Service
Service #5
5. Date*

MonthDayYear
5. Service Provided*
5. Provider Classification*
5. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
5. Total for this Service
Service #6
6. Date*

MonthDayYear
6. Service Provided*
6. Provider Classification*
6. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
6. Total for this Service
Service #7
7. Date*

MonthDayYear
7. Service Provided*
7. Provider Classification*
7. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
7. Total for this Service
Service #8
8. Date*

MonthDayYear
8. Service Provided*
8. Provider Classification*
8. Units Provided*
Examples: 1 Unit = 15 Mins, 4 Units = 1 Hour
8. Total for this Service
Voucher Total
Discharge
Was the patient Discharged from the Voucher Program funding this month?*

NoYes
Date of Discharge:*

MonthDayYear
Date
Has the patient discharge been completed in state system?*

NoYes
Attestations
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.
I attest that all services being submitted on this receipt meet the requirements and expectations of our contract.
Reviewer Name:*
Receipt Submission Date:*

MonthDayYear
Email
Enter your email if you would like to receive an email copy of this form
An Invoice from your organization is required for processing receipts for payment. If you have questions, contact, vouchers@sageprojectconsultants.com.
Dynamic Dropdowns
Sage Approver
Sage Approved Date

MonthDayYear
Date
Should be Empty:

Child Care Provider Receipt