Form DR385A "Supported Employment - Individual - Invoice Summary" - California

What Is Form DR385A?

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 July 1, 2016;
  • 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 fillable version of Form DR385A by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Form DR385A "Supported Employment - Individual - Invoice Summary" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Date:
SUPPORTED EMPLOYMENT – INDIVIDUAL – INVOICE SUMMARY
DR385A (Rev. 07/16)
:
REMIT PAYMENT TO
DOR District Office Name & Address:
(SE Service Provider Name & Address)
Department of Rehabilitation
SEP #:
Federal Tax ID #:
Billing Month/Year: Invoice # (optional):
# DR385B Attached:
INSTRUCTIONS:
 Individual Placement (IP) SE Services must be documented by the following:
o Intake - attach the first DR382 - SE - Placement Services Progress Report.
o Placement - attach the DR383 - SE - Job Placement Information.
o Retention - attach the third DR384 - SE - Monthly Job Coach Report.
o Individual Job Coach Hours - attach (1) DR385B detail sheets and (2) page 2 of
the DR384. Hours invoiced cannot exceed the authorized hours. If the hours on the
DR384 exceed the authorized amount, only the authorized amount can be billed.
 Submit an original signed in blue ink and one (1) copy.
 Write "Individual Supported Employment Invoice" on the envelope.
 Mail to the DOR District Office, Attention: SEP Invoice Coordinator.
Total #
Total
Rate
Total Amount
Consumers
Hours
Intake (IP)
$360.00
Placement (IP only)
$720.00
Retention (IP only)
$720.00
Job Coaching (IP)
$36.57/hr
TOTAL INVOICE AMOUNT
For each of the services invoiced, I understand that payment from DOR is payment in full for the services provided,
pursuant to Title 9 CCR Section 7322. I certify that I am authorized to make such certification for the above-named
rehabilitation facility that (1) no duplicate payment or other funding has been received or is anticipated from any source for
the same consumer, service and service period; and (2) the services invoiced have been provided.
Signature (use blue ink):
Completed by (type or print):
Phone Number:
Email:
Approved by:
Date:
DOR USE ONLY: Approved for payment based
on documentation of services provided.
Distribution:
DOR District Office
Service Provider
Attachments:
DR385B
DR382
DR383
DR384
NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State 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
Date:
SUPPORTED EMPLOYMENT – INDIVIDUAL – INVOICE SUMMARY
DR385A (Rev. 07/16)
:
REMIT PAYMENT TO
DOR District Office Name & Address:
(SE Service Provider Name & Address)
Department of Rehabilitation
SEP #:
Federal Tax ID #:
Billing Month/Year: Invoice # (optional):
# DR385B Attached:
INSTRUCTIONS:
 Individual Placement (IP) SE Services must be documented by the following:
o Intake - attach the first DR382 - SE - Placement Services Progress Report.
o Placement - attach the DR383 - SE - Job Placement Information.
o Retention - attach the third DR384 - SE - Monthly Job Coach Report.
o Individual Job Coach Hours - attach (1) DR385B detail sheets and (2) page 2 of
the DR384. Hours invoiced cannot exceed the authorized hours. If the hours on the
DR384 exceed the authorized amount, only the authorized amount can be billed.
 Submit an original signed in blue ink and one (1) copy.
 Write "Individual Supported Employment Invoice" on the envelope.
 Mail to the DOR District Office, Attention: SEP Invoice Coordinator.
Total #
Total
Rate
Total Amount
Consumers
Hours
Intake (IP)
$360.00
Placement (IP only)
$720.00
Retention (IP only)
$720.00
Job Coaching (IP)
$36.57/hr
TOTAL INVOICE AMOUNT
For each of the services invoiced, I understand that payment from DOR is payment in full for the services provided,
pursuant to Title 9 CCR Section 7322. I certify that I am authorized to make such certification for the above-named
rehabilitation facility that (1) no duplicate payment or other funding has been received or is anticipated from any source for
the same consumer, service and service period; and (2) the services invoiced have been provided.
Signature (use blue ink):
Completed by (type or print):
Phone Number:
Email:
Approved by:
Date:
DOR USE ONLY: Approved for payment based
on documentation of services provided.
Distribution:
DOR District Office
Service Provider
Attachments:
DR385B
DR382
DR383
DR384
NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State 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.