SOUTHERN ALABAMA REGIONAL COUNCIL ON AGING (SARCOA)
Area Agency on Aging
530 Medicaid Waiver
Voucher Summary Sheet EXHIBIT I

Contractor: ______

Telephone: ______

Address: ______

Month: ______Year: ______

CONTRACTOR / SARCOA USE ONLY
SERVICE / TOTAL
RATE
PER HOUR / TOTAL
EXACT HOURS
(15 Minute Increments) / DOLLAR
AMOUNT
BILLED / TOTAL
EXACT HOURS / TOTAL
RATE
PER UNIT
1 unit = 15 min. / TOTAL UNITS / TOTAL $$$
HOMEMAKER / $ 14.96/hr / $ / $3.74/unit / $
PERSONAL
CARE / $ 14.96/hr / $ / $3.74/unit / $
UNSKILLED
RESPITE / $ 14.40/hr / $ / $ 3.60/unit / $
SKILLED
RESPITE / $ 20.72/hr / $ / $5.18/unit / $
COMPANION
SERVICES / $ 11.04/hr / $ / $2.76/unit / $
SKILLED NURSING (RN) / $ 28.48/hr / $7.12/unit
SKILLED NURSING (LPN) / $ 20.72/hr / $ 5.18/unit
$ / $
I REQUEST REIMBURSEMENT FOR SERVICES ADMINISTERED UNDER THE MEDICAID WAIVER PROGRAM. THE SIGNATURE APPEARING BELOW MUST BE ON FILE WITH THE AREA AGENCY ON AGING (SARCOA) AS AN AUTHORIZED SIGNATURE.

______

ADMINISTRATOR / OFFICIAL DATE

SARCOA-10-1-2015