ALIGNSTAFFING

RESPITE CARE NETWORK (RCN)

RESPITE CARE PROVIDER INVOICE VOUCHER

1. Name of Respite Care Provider: __________

2. Social Security Number or Employer Identification Number: ____

3. Address:

4. Telephone: ___________________________ Cell: __________________________

5. Fax: __________________________ Email Address:

6. Installation: EFMP Manager/Designee:

7. Respite Care Recipient:

8. RCN Case Record Number: Month/Year:

9. Hours Authorized: _________________ Hourly Rate:

10. Fax the payment packet no later than the 4th working day of the following month:

• Invoice Voucher
• Respite Care Provider Satisfaction Survey

Total Total
11. Hours Hours
Date In Out In Out Worked Date In Out In Out Worked
1 17
2 18
3 19
4 20
5 21
6 22
7 23
8 24
9 25
10 26
11 27
12 28
13 29
14 30
15 31
16

12. Grand Total Hours:

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I certify that these hours are true and accurate.
13.
Sponsor/Parent/Guardian Signature Date

I certify that these hours are true and accurate.

14.
Respite Care Provider Signature Date

15. Comments/Notes:

Fax All Documents RCN Accounting: 1-866-565-9307

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