Sheet 1: Updated 10-18-11

	
	
	
	
	
	
	
	
	
	
	

		
CDS Billing Form
		
	

		
146 State House Station, Augusta, ME  04333 (207)624-6686 Fax (207)624-6837
		
	

		
*****Bill One Month Per Invoice and One Child Per Invoice*****
		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


	
	

		
Site Child is Affilliated with (Cumberland/York etc)  
		


		


		


		


		


		
For B-2
		


		
For 3-5
		


	
	

		


		


		


		


		


		


		


		


		


		


	
	

		
Provider Name:
		


		


		


		
Inv Date:
		


		


	
	

		
Address:
		


		


		


		
Invoice #:
		


		
	

		


		


		


		


		
EIN/SSN:
		


		
	

		
Phone No.:                                 Fax No.:                                    E Mail:
		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


	
	

		
Child's Information
		
	

		
Name:
		


		
DOB:
		


		


		


		


	
	

		
Date IEP/IFSP Began:________Date IEP/IFSP Ends:__________ Funding Source:   INS ______MED_______CDS______
		


		


		


		


		


		


		


		


		


	
	

		
Usual & Customary Rate:_______________________________________________
		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		
*****Bill One Child Per Invoice*****
		


		


		


	
	

		
   Please indicate billing units:
		


		
_____15 min units    _____30 min units   ____60 min units
		


		


		


		
*****Bill One Month Per Invoice*****
		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


	
	

		


		
Make-up
		


		
# of *Units or
		
Unit
		
Service
		
 Travel
		
Travel
		
Travel
		


	
	

		
Service Date
		
Session
		
Description of Service 
		
SI Sessions
		
 Rate 
		
 Total 
		
 Miles 
		
 Rate 
		
 Total 
		
 Total 
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		


		


		


		
 -   
		


		
 0.44 
		
 -   
		
 -   
	
	

		


		


		
   Total Amount Due:
		


		


		
 $-   
		


		


		
 $-   
		
 $-   
	
	

		


		


		


		


		


		


		


		


		


		


	
	

		
Provider must bill CDS within 30 days of service delivery and/or travel time unless a 3rd party is being billed.
		


		


		


		


		


		


		


		


		


	
	

		
Submissions must be prompt.
		


		


		


		


		


		


		


		


		


	
	

		
Please attach any insurance or medicaid explanations of benefits to this bill.
		


		


		


		


		


		


		


		


		


	
	

		
To receive payment, provider must forward quarterly progress notes by the end of each quarter.
		


		


		


		


		


		


		


		


		


	
	

		
Date that progress notes were forwarded to CDS Site:__________________________________
		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


	
	

		
Signature:_________________________________________________  Date:_______________________