Form DR385C "Supported Employment (Se) - Group - Invoice Summary" - California

What Is Form DR385C?

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 January 1, 2017;
  • 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 DR385C by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Form DR385C "Supported Employment (Se) - Group - Invoice Summary" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
– GROUP – INVOICE SUMMARY
SUPPORTED EMPLOYMENT
Date:
DR385C (Rev 01/17)
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): # DR385D-E Attached:
INSTRUCTIONS:
Complete separate detail sheets for group intake (DR385D) and group job coaching (DR385E).
DR385C must be supported by the following documentation:
o
Group Intake - attach (1) DR385D and (2) DR382 - SE- Placement Services Progress Report.
o
Group Job Coach - attach (1) DR385E detail sheets, (2) DR384, and (3) DS1964. Actual allocated hours
for the services provided cannot exceed the authorized hours on DR297JC. If the Allocated Job
Coaching Hours by Consumer on the DS1964 exceed the Job Coach Hours per Month authorized, bill
only the Maximum Job Coach Hours per Month.
Complete one DR385C summary sheet for all DR385D&E detail sheets.
Submit original signed in blue ink and one (1) copy.
Write "Group Supported Employment Invoice" on the envelope.
Mail to the DOR District Office, Attention: SEP Invoice Coordinator.
Total
Rate
Total Amount
Total #
Hours
Consumers
$360.00
Intake
Job Coaching (GP)
$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:
Approved by:
Date:
DOR USE ONLY: Approved for payment based
on documentation of services provided.
Distribution:
DOR District Office
Service Provider
Attachments:
DR385D
DR382
DR297JC
Sent Simultaneously to Other Parties:
DR384 to counselor
DS1964 to DORSEP
@dor.ca.gov
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
– GROUP – INVOICE SUMMARY
SUPPORTED EMPLOYMENT
Date:
DR385C (Rev 01/17)
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): # DR385D-E Attached:
INSTRUCTIONS:
Complete separate detail sheets for group intake (DR385D) and group job coaching (DR385E).
DR385C must be supported by the following documentation:
o
Group Intake - attach (1) DR385D and (2) DR382 - SE- Placement Services Progress Report.
o
Group Job Coach - attach (1) DR385E detail sheets, (2) DR384, and (3) DS1964. Actual allocated hours
for the services provided cannot exceed the authorized hours on DR297JC. If the Allocated Job
Coaching Hours by Consumer on the DS1964 exceed the Job Coach Hours per Month authorized, bill
only the Maximum Job Coach Hours per Month.
Complete one DR385C summary sheet for all DR385D&E detail sheets.
Submit original signed in blue ink and one (1) copy.
Write "Group Supported Employment Invoice" on the envelope.
Mail to the DOR District Office, Attention: SEP Invoice Coordinator.
Total
Rate
Total Amount
Total #
Hours
Consumers
$360.00
Intake
Job Coaching (GP)
$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:
Approved by:
Date:
DOR USE ONLY: Approved for payment based
on documentation of services provided.
Distribution:
DOR District Office
Service Provider
Attachments:
DR385D
DR382
DR297JC
Sent Simultaneously to Other Parties:
DR384 to counselor
DS1964 to DORSEP
@dor.ca.gov
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.