Reimbursement Program PHMC Invoice Request

(for invoices that will be submitted to and reimbursed by PHMC)

Today's Date

YYYY

Referral Partner Code#

Organization Name

Organization Representative Email

Case Manager's Telephone Number

(###)

###

####

DHS Case Number

Caregiver's Name

Caregiver's Telephone Number

(###)

###

####

Caregiver's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Caregiver's Language

Number of Single Beds Requested:

Number of Bunk Beds Requested:

Number Encasements Requested:

Number of Dressers Requested

Names, Ages and Genders for all children needing beds

Comments/Notes