Provider Claim Form

Data Elements: ProviderClaimForm.aspx

Name:

Phone:

E-mail Address:

Services for the month of:

Mental Health Provider:

Group date, time, and location:

Participant Name	Date of Attendance	Date of Attendance	Date of Attendance	Date of Attendance	Date of Attendance	Date of Attendance	Date of Attendance

Number of clients seen:

	# Members/Clients/Groups	Total
Claim for Groups ($100.00)		$0
Claim for assessments ($80.00)		$0
Claim for Individual ($65.00)		$0
Claim for Family Group ($100.00)		$0
Claim for Family Individual ($65.00)		$0
Claim for Presentation(s) ($100/hr): hours		$0
	Final Total:	$0

Presentation description (number in attendance):

Support our mission of education and increasing the availability of services for problem gambling and their families