Invoice Form

Employee Name *

(If applicable, please include your LLC and then full name in parenthesis)

Hospital Code *

Case Type * 🛈

Start Date * +

End Date * +

Total Billable Days *

Email Address *

Cogs - Labor : Contract Labor

Cogs Start Date 1 +

Cogs End Date 1 +

Contract/Service Description 1

Amount 1

Cogs Start Date 2 +

Cogs End Date 2 +

Contract/Service Description 2

Amount 2

Cogs Start Date 3 +

Cogs End Date 3 +

Contract/Service Description 3

Amount 3

Cogs Start Date 4 +

Cogs End Date 4 +

Contract/Service Description 4

Amount 4

Cogs Start Date 5 +

Cogs End Date 5 +

Contract/Service Description 5

Amount 5

Cogs Start Date 6 +

Cogs End Date 6 +

Contract/Service Description 6

Amount 6

Cogs Start Date 7 +

Cogs End Date 7 +

Contract/Service Description 7

Amount 7

Upload

COGS - Labor Total:

$0.00

CT Date 1 +

Miles 1

Rate 1

Description 1

1 Total Mile $

0.00

CT Date 2 +

Miles 2

Rate 2

Description 2

2 Total Mile $

0.00

CT Date 3 +

Miles 3

Rate 3

Description 3

3 Total Mile $

0.00

CT Date 4 +

Miles 4

Rate 4

Description 4

4 Total Mile $

0.00

CT Date 5 +

Miles 5

Rate 5

Description 5

5 Total Mile $

0.00

CT Date 6 +

Miles 6

Rate 6

Description 6

6 Total Mile $

0.00

CT Date 7 +

Miles 7

Rate 7

Description 7

7 Total Mile $

0.00

Miles Documentation

Mileage Total

0.00

Travel Expenses

Travel Date 1 +

Expense type 1 *

Travel Amount 1

File(s) to upload 1

Travel Date 2 +

Expense type 2 *

Travel Amount 2

File(s) to upload 2

Travel Date 3 +

Expense type 3 *

Travel Amount 3

File(s) to upload 3

Travel Date 4 +

Expense type 4 *

Travel Amount 4

File(s) to upload 4

Travel Date 5 +

Expense type 5 *

Travel Amount 5

File(s) to upload 5

Travel Date 6 +

Expense type 6 *

Travel Amount 6

File(s) to upload 6

Travel Date 7 +

Expense type 7 *

Travel Amount 7

File(s) to upload 7

Travel Date 8 +

Expense type 8 *

Travel Amount 8

File(s) to upload 8

Travel Date 9 +

Expense type 9 *

Travel Amount 9

File(s) to upload 9

Travel Date 10 +

Expense type 10 *

Travel Amount 10

File(s) to upload 10

Travel Expense Total:

0.00

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