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Currency [0]/Explanatory TextG5Explanatory Text % 0Good;Good  a%1 Heading 1G Heading 1 I}%O2 Heading 2G Heading 2 I}%?3 Heading 3G Heading 3 I}%234 Heading 49 Heading 4 I}%5( Hyperlink 6InputuInput ̙ ??v% 7 Linked CellK Linked Cell }% 8NeutralANeutral  e%"Normal 9Noteb Note   :OutputwOutput  ???%????????? ???;$Percent <Title1Title I}% =TotalMTotal %OO> Warning Text? Warning Text %XTableStyleMedium2PivotStyleLight16`x8Updated 10-18-11(mSheet22oSheet381+Child's InformationDates of ServiceDescription of ServiceRateTotal^To receive payment, provider must forward quarterly progress notes by the end of each quarter.Description of Service  Total Amount Due:NPlease attach any insurance or medicaid explanations of benefits to this bill.Submissions must be prompt.ServiceTravel TravelMake-upSession# of *Units orUnit! Please indicate billing units:FUsual & Customary Rate:_______________________________________________9_____15 min units _____30 min units ____60 min units Service DateCDS Billing FormK146 State House Station, Augusta, ME 04333 (207)624-6686 Fax (207)624-6837YSignature:_________________________________________________ Date:_______________________$Bill One Month Per InvoicepProvider must bill CDS within 30 days of service delivery and/or travel time unless a 3rd party is being billed.0Mo>Bill One Month Per Invoice and One Child Per Invoice$Bill One Child Per InvoiceMilesVDate that progress notes were forwarded to CDS Site:__________________________________ SI SessionsFor B-2For 3-5iDate IEP/IFSP Began:________Date IEP/IFSP Ends:__________ Funding Source: INS ______MED_______CDS______Name:DOB:Provider Name:Address:^Phone No.: Fax No.: E Mail: Invoice #:EIN/SSN:6Site Child is Affilliated with (Cumberland/York etc) Inv Date:21 23467ccB g2ɀ /XfNl  dMbP?_*+%&C&8A Statewide, interdepartmental coordination network of services for fb88 families and children, (0-5) with disabilities. CDS is an Equal Opportunity Employer&R&D&?'?(?)?Mz\\oit-isa1psprt01\DOE-5200CDSC odXXLetterDINU"x _S<xSMTJhHP LaserJet 5200 PCL 5eInputBinTray3_optRESDLLUniresDLLOrientationPORTRAITHPOrientRotate180FalsePaperSizeLETTERHPDocUISUITrueMediaTypeAUTOESPRITSupportedTrueEconomodeFalseTextAsBlackFalseTTAsBitmapsSettingTTModeOutlineGraphicsModeRASTERMODEHPDocPropResourceDatahpchl5r1.cabPrintQualityGroupPQGroup_1HPColorModeMONOCHROME_MODEHPPDLTypePDL_PCL5HPMaxResolutionPDM_600DPIHPPJLEncodingUTF8HPJobAccountingHPJOBACCT_JOBACNT_COLORAUTHHPBornOnDateHPBODHPJobByJobOverrideJBJOHPSmartDuplexSinglePageJobTrueHPSmartDuplexOddPageJobTrueHPManualDuplexDialogItemsInstructionID_01_FACEDOWN-NOROTATEHPManualFeedOrientationFACEDOWNHPOutputBinOrientationFACEDOWNHPManualDuplexDialogModelModelessHPMapManualFeedToTray1TrueHPManualDuplexPageRotateDriverRotateHPStraightPaperPathFalseHPNUseDiffFirstPageChoiceTRUEHPPageExceptionsFileHPCPE5r1HPPageExceptionsInterfaceShowPageExceptionsHPPageExceptionsLowEndHPPageExceptionsLowEndVerHPPageExceptionsCoverInsertionHPConsumerCustomPaperTrueHPEnableRAWSpoolingTrueHPPrintOnBothSidesManuallyFalseHPJobAccWoPinTruePSAlignmentFileHPCLS5r1HPSmartHub_OnlinediagnostictoolsTRUEHPSmartHub_SupportandtroubleshootingTRUEHPSmartHub_ProductmanualsTRUEHPSmartHub_CheckfordriverupdatesTRUEPSServices_DeviceandSuppliesStatusTRUEHPSmartHubInet_SID_263_BID_276_HID_265PSServicesOptionPrnStat_SID_242_BID_270_HID_15521Resolution600dpiDuplexNONECollateOFFAlternateLetterHeadFalseHPPaperSizeALMConstraintsENV_10HPCustomDUplexableRange8.27x5.83_11.69x17HPXMLFileUsedhpc52005.xmlHPDuplicateJobNameOverrideSWFWJRConstraintsJRCHDPartialJRHDInstalledJRHDOffJRHDNotInstalledJRHDOffHPPaperSizeDuplexConstraintsSTATEMENTHPMediaTypeDuplexConstraintsCARDSTOCKIUPHxAoAߖhHKo^pP1*,%RIjR0]0 x׏wM?'2,]I--}0ξe޾ٙ݋4OI -y!q0 5*L~HIwVʯІFfne܆8H[V$A;t6wRZzIk e¡84+}OE ,= _k zPӚnkrw@Тvm8ha J5mz}E~la㓁_6oVW Sw!*qپ铷 6(h.s)L$JEEIA3'}=ٟDtx6Ztj9rOcKqQ )bXQF^RR,9$jB[3DO`& o0=vJ埥 DJٛ/=ǯ6>|wpk7N.%D>kaaaad#W"UXX??&U} } $} I} $ } }  } m } I } } /  h   @ J@ @ @ @ @ @ @  J@ @ @ @ @ J@ i@   @ @ @ @ @ @ @ @ @ @ @ @ lmmlmmmmmm mmnnmmmmmm {|||ssmmmm mmnnmmmmms v)d uA u  Ad S$ || a* }z S% || T' ~|| S|| T( || S& SFF ^ ?????????] o ommmmmmmm w" yzz N# z x! 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