Completion Instructions - HR0150A

Facility/Residence Invoice - Daily User Rate

Service Provider

 A: Facility/Residence Type

1. Indicate the type of facility/residence by checking the appropriate box

 B: Invoice Information

1. Enter the 'Year' first then the 'Month' to which the invoice applies

2. Enter the Payee name

3. Enter the Service Provider name in which care is provided if different from above

4. Enter the license or registration number of the facility/residence and bed capacity supporting the Facility/

Residence Type indicated in Section A. If not registered or licensed, enter N/A (not applicable) in both boxes

5. Service provider signing officer must certify the information recorded is correct and the date they certified this

information

 C: Client Invoice Lines

A. Enter Social Insurance Number (SIN) or Personal Health Number (PHN)

B. Enter the first and last name for each client being billed for (this form may be used for more than one client)

C. Enter the birth date of each client being billed for

D. Enter the number of days that the client was in care during the billing period

E. Enter the daily rate

F. Calculate the total charged based on the number of days the client was in care

G. Enter the total dollar amount contributed by the client, and/or contributed on behalf of the client

H. Enter the total dollar amount billed by subtracting the amount shown in (G) from the amount shown in (F), and

enter the answer in (H)

 Note: do not balance forward  (every page is separate).

Total separately, columns F and H. In each "Total" box, enter the applicable figure.