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    Genworth Blank Document

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    Esliten ATG
    This document is an invoice for independent healthcare providers. It provides billing information for services provided to an insured individual, including the caregiver's name, dates and times of shifts, tasks performed during each shift, and totals for hours worked, mileage, and the overall invoice charge. Signatures from the insured and caregiver are required at the bottom to confirm the provided services.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Genworth Blank Document

    Uploaded by

    Esliten ATG
    38 views1 page
    This document is an invoice for independent healthcare providers. It provides billing information for services provided to an insured individual, including the caregiver's name, dates and times of shifts, tasks performed during each shift, and totals for hours worked, mileage, and the overall invoice charge. Signatures from the insured and caregiver are required at the bottom to confirm the provided services.

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    This document is an invoice for independent healthcare providers. It provides billing information for services provided to an insured individual, including the caregiver's name, dates and times of shifts, tasks performed during each shift, and totals for hours worked, mileage, and the overall invoice charge. Signatures from the insured and caregiver are required at the bottom to confirm the provided services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    38 views1 page

    Genworth Blank Document

    Uploaded by

    Esliten ATG
    This document is an invoice for independent healthcare providers. It provides billing information for services provided to an insured individual, including the caregiver's name, dates and times of shifts, tasks performed during each shift, and totals for hours worked, mileage, and the overall invoice charge. Signatures from the insured and caregiver are required at the bottom to confirm the provided services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    BST

    Invoice for Independent Health Care Providers


    Mail Address: Genworth Life & Annuity Insurance Company, Insured’s Name: Lili S Yang
    ____________________________
    Genworth Life Insurance Company,
    Genworth Life Insurance Company† Policy Number: AAA5011817
    ____________________________
    Attn: LTCI Claims Claim Number: A313068
    ____________________________
    P.O. Box 40007, Lynchburg, VA 24506-9939
    Fax Number: 888 557.5526
    Phone Number: 800 876.4582 Caregiver’s Name: ____________________________
    Visit Us Online: www.genworth.com/login.html (PLEASE PRINT)

    Tasks Performed
    (Key shown below)
    Shift Shift Shift Shift Location Location

    AM

    HM
    CO
    BA
    DR

    TO
    EA

    CS
    TR
    Date Hours
    Start1 End1 Rate Charge In2 Out2

    Tasks Key
    Total Total BA (Bathing)
    Hours: Charge: DR (Dressing)
    TR (Transferring)
    (Transportation for medically necessary, life- CO (Continence)
    Miles Mileage sustaining or safety functions in service to TO (Toileting)
    Amount: the Insured. The normal rate approved is the EA (Eating)
    Driven: IRS medical rate ($0.19/mile). Please AM (Ambulation)
    contact us for exceptions to this process.) CS (Cognitive Supervision)
    HM (Homemaker Services)
    Total Invoice Charge: (Total Charge + Mileage Amount)
    Fraud Notice:
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
    presents false information in an application for insurance is guilty of a crime and may be subject to fines and
    confinement in prison.
    Signature of Insured or Authorized Representative: _________________________________________ Date: __________
    Signature of Caregiver: _______________________________________________________________ Date: __________
    †Only Genworth Life Insurance Company of New York is licensed in New York.

    ¹ Indicate AM or PM for “Shift Start” and “Shift End”


    ² Location In/Out refers to where the Caregiver is at the start and end of each shift (i.e., Insured’s Home, Caregiver’s Home, Doctor, etc.) (Rev 09/2016)

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