Sample Form DR386 "Invoice Discrepancy Notice - Sep/Wap" - California

What Is Form DR386?

This is a legal form that was released by the California Department of Rehabilitation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2008;
  • The latest edition provided by the California Department of Rehabilitation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DR386 by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Sample Form DR386 "Invoice Discrepancy Notice - Sep/Wap" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
INVOICE DISCREPANCY NOTICE - SEP/WAP
DR386 (Rev. 02/08)
Vendor Name & Address:
DOR District Office Name & Address:
Independent Opportunity Support Center
Greater Los Angeles District
12345 Independence Boulevard
3251 West 6th Street, Suite 300
Funkytown, CA 91233
Los Angeles, CA 90020-5017
Attn: Melani LeClerc
SEP or WAP #:
Invoice Month/Year:
Invoice Number (if used):
SEP
WAP
999
12/2008
123456789012345
Instructions:
If appropriate, submit a new corrected invoice as soon as possible. The new invoice must show the
original invoice month and the appropriate progress report(s) must accompany the invoice.
Reason
Codes:
1. Consumer not on file in this district.
6. Consumer invoiced following VR case closure.
2. No authorization on file, authorization insufficient, or
7. No original signature.
expired.
8. Invoice already paid.
3. Progress report missing.
9. Incorrect computations.
4. Data does not match invoice (authorization number,
10. Erasures or white-outs.
consumer name).
11. Other: not applicable
5. Invoiced hours are not supported by progress report.
The following consumer(s) were deleted from the invoice:
Invoice
Reason
Consumer Name
Authorization
DOR Counselor
Amount
Code
(Last, First)
Number
(Last Name)
Deleted
7
Jorgenson, Wilhelmina
99-1234567
Hamilton
1027.60
7
Jingleheimer-Schmidt,
99-1234567
Hamilton
924.84
John J
Original Invoice Amount
1952.44
Total Amount Deducted from the Invoice
1952.44
Amount Processed for Payment (Original Invoice Amount less Total Deducted)
1952.44
DOR Account Tech Name:
Phone Number:
Date:
If you have any questions,
Penny Wise
213-736-3904
01/15/2008
please contact:
Distribution:
DOR District Office
SEP/WAP Service Provider
NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State and federal law and
departmental regulations prohibit you from making any further disclosure of this information without the informed, written consent of the
person to whom this information pertains.
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
INVOICE DISCREPANCY NOTICE - SEP/WAP
DR386 (Rev. 02/08)
Vendor Name & Address:
DOR District Office Name & Address:
Independent Opportunity Support Center
Greater Los Angeles District
12345 Independence Boulevard
3251 West 6th Street, Suite 300
Funkytown, CA 91233
Los Angeles, CA 90020-5017
Attn: Melani LeClerc
SEP or WAP #:
Invoice Month/Year:
Invoice Number (if used):
SEP
WAP
999
12/2008
123456789012345
Instructions:
If appropriate, submit a new corrected invoice as soon as possible. The new invoice must show the
original invoice month and the appropriate progress report(s) must accompany the invoice.
Reason
Codes:
1. Consumer not on file in this district.
6. Consumer invoiced following VR case closure.
2. No authorization on file, authorization insufficient, or
7. No original signature.
expired.
8. Invoice already paid.
3. Progress report missing.
9. Incorrect computations.
4. Data does not match invoice (authorization number,
10. Erasures or white-outs.
consumer name).
11. Other: not applicable
5. Invoiced hours are not supported by progress report.
The following consumer(s) were deleted from the invoice:
Invoice
Reason
Consumer Name
Authorization
DOR Counselor
Amount
Code
(Last, First)
Number
(Last Name)
Deleted
7
Jorgenson, Wilhelmina
99-1234567
Hamilton
1027.60
7
Jingleheimer-Schmidt,
99-1234567
Hamilton
924.84
John J
Original Invoice Amount
1952.44
Total Amount Deducted from the Invoice
1952.44
Amount Processed for Payment (Original Invoice Amount less Total Deducted)
1952.44
DOR Account Tech Name:
Phone Number:
Date:
If you have any questions,
Penny Wise
213-736-3904
01/15/2008
please contact:
Distribution:
DOR District Office
SEP/WAP Service Provider
NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State and federal law and
departmental regulations prohibit you from making any further disclosure of this information without the informed, written consent of the
person to whom this information pertains.