All names and numbers are fictitious. Any similarity to to any real persons is purely coincidental
Capital Health Authority Service Invoice Sample
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Invoice to: Capital Health Authority Home Care Program
Agency: My Caring Agency
Address: #1302, 500 Street Record For: 03 / 10 Page 1 of 2
Edmonton, AB Health Unit 02
Postal Code: T6L 1C1 Telephone: 780 413 1840 Office ____
| Home | | | |Serv|Serv| | |Cost per| Total |Li
| Care |Prov|Employee| |Sub-|Desc|Units/|Hours/| Hour, | Cost |ne
Client's Last Name | ID |Type| No. |Day|Cat.| A/B|Visits| Days | Unit | |No
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BROWN, HILDA | 4493 | H | | 30| S3 | C | 2 | 8.00| 13.25 | 106.00| 1
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GREEN, KAYE | 7881 | H | | 30| S3 | C | 2 | 6.00| 13.25 | 79.50| 2
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WHITE, GERDA | 11351 | H | | 30| S3 | C | 4 | 8.00| 13.25 | 106.00| 3
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ORANGE, RAE | 11750 | H | | 30| S3 | C | 4 | 8.00| 13.25 | 106.00| 4
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ATKINS, AL | 12029 | H | | 30| S3 | C | 1 | 3.00| 13.25 | 39.75| 5
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MILLS, FLOWER | 13158 | H | | 30| S3 | C | 1 | 3.00| 13.25 | 39.75| 6
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LENT, ALENE | 14263 | H | | 30| S3 | C | 3 | 9.00| 13.25 | 119.25| 7
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CALKINS, MIKE | 16524 | H | | 30| S3 | C | 2 | 8.00| 13.25 | 106.00| 8
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KORN, WILMA | 16525 | H | | 30| S3 | C | 2 | 8.00| 13.25 | 106.00| 9
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DAY, DORIS | 18162 | H | | 30| S3 | C | 2 | 8.00| 13.25 | 106.00|10
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DINGEY, RUBBER | 18191 | H | | 30| S3 | C | 2 | 6.00| 13.25 | 79.50|11
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MATA, HARRY | 18408 | H | | 30| S3 | C | 2 | 6.00| 13.25 | 79.50|12
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BAIER, FRED | 18774 | H | | 30| S3 | C | 2 | 4.00| 13.25 | 53.00|13
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FISCHER, BOB | 19274 | H | | 30| S3 | C | 3 | 6.00| 13.25 | 79.50|14
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TOMAS, HELEN | 19281 | H | | 30| S3 | C | 2 | 4.00| 13.25 | 53.00|15
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LANCE, ANN | 19443 | H | | 30| S3 | C | 2 | 6.00| 13.25 | 79.50|16
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WOODLEY, ALMA | 20093 | H | | 30| S3 | C | 4 | 12.00| 13.25 | 159.00|17
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NELSON, BILL | 20100 | H | | 30| S3 | C | 2 | 4.00| 13.25 | 53.00|18
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Other Charges
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| Hours | Cost/Hour | Total Cost
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SUMMARY REPORT
Total Standard
Code Ext. Description Hours Rate Billed
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S3C H Homemaker 284.00 13.25 3763.00
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Totals: 284.00 3763.00
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