"Clinical Consultation Template (Rn & Ba)" - Delaware

This Delaware-specific "Clinical Consultation Template (Rn & Ba)" is a document released by the Delaware Health and Social Services.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Clinical Consultation Template (Rn & Ba)" - Delaware

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DDDS CLINICAL CONSULTATIVE (Enter Provider Name)
CLINICAL CONSULTATIVE (Enter PROVIDER ADDRESS, CITY, STATE, ZIP CODE)
PHONE #:
( ### ) ### - ####
FAX #:
( ### ) ### - ####
FEDERAL TAX ID#
## - #######
Delaware Health and Social Services
Invoice Number:
#####
Division of Developmental Disabilities Services
Invoice Date:
00/00/0000
Office of Budget, Contracts & Business Services
Terms:
Due Upon Receipt
Contract Manager
Services From:
00/00-00/00
1054 South Governor's Avenue
Type of Service:
Clinical Consultative
Dover, DE 19904
PART ONE - CLINICAL BEHAVIORAL CONSULTATION
Please report hours per day per consumer
Consumer
Residential
Date of
Billable
Hourly
Monthly Services
Name
Site Location
Service
Hours
Rate
(Billable * Rate)
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
SUBTOTAL (BEHAVIORAL):
$
-
PART TWO - CLINICAL NURSING CONSULTATION
Please report hours per day per consumer
Consumer
Residential
Dates of
Billable
Hourly
Monthly Services
Name
Site Location
Service
Hours
Rate
(Billable * Rate)
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
SUBTOTAL (NURSING):
$
-
CLINICAL CONSULTATIVE INVOICE SUMMARY
CLINICAL BEHAVIORAL CONSULTATIVE SERVICES (PART ONE) :
$
-
CLINICAL NURSING CONSULTATIVE SERVICES (PART TWO) :
$
-
TOTAL MONTHLY EXPENDITURE :
$
-
DDDS CLINICAL CONSULTATIVE (Enter Provider Name)
CLINICAL CONSULTATIVE (Enter PROVIDER ADDRESS, CITY, STATE, ZIP CODE)
PHONE #:
( ### ) ### - ####
FAX #:
( ### ) ### - ####
FEDERAL TAX ID#
## - #######
Delaware Health and Social Services
Invoice Number:
#####
Division of Developmental Disabilities Services
Invoice Date:
00/00/0000
Office of Budget, Contracts & Business Services
Terms:
Due Upon Receipt
Contract Manager
Services From:
00/00-00/00
1054 South Governor's Avenue
Type of Service:
Clinical Consultative
Dover, DE 19904
PART ONE - CLINICAL BEHAVIORAL CONSULTATION
Please report hours per day per consumer
Consumer
Residential
Date of
Billable
Hourly
Monthly Services
Name
Site Location
Service
Hours
Rate
(Billable * Rate)
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
CONSUMER LAST NAME, FIRST NAME
Behavioral
0.00
$
14.08
$
-
SUBTOTAL (BEHAVIORAL):
$
-
PART TWO - CLINICAL NURSING CONSULTATION
Please report hours per day per consumer
Consumer
Residential
Dates of
Billable
Hourly
Monthly Services
Name
Site Location
Service
Hours
Rate
(Billable * Rate)
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
CONSUMER LAST NAME, FIRST NAME
Nursing
0.00
$
13.36
$
-
SUBTOTAL (NURSING):
$
-
CLINICAL CONSULTATIVE INVOICE SUMMARY
CLINICAL BEHAVIORAL CONSULTATIVE SERVICES (PART ONE) :
$
-
CLINICAL NURSING CONSULTATIVE SERVICES (PART TWO) :
$
-
TOTAL MONTHLY EXPENDITURE :
$
-
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