Chapter 514 - Nursing Facility Services - DHHR - State of West ...

West Virginia Department of Health and Human ResourcesBureau for Medical ServicesInvoice for ReimbursementNurse Aide Training and Competency EvaluationThis form is to be submitted with all documentation as listed on page 2 of this invoice, to the Bureau forMedical Services.PurposeFacility I.D.( ) 1. Nurse Aide Training Cost Provider Number:( ) 2. Competency Evaluation Cost Facility Name:Nurse Aide Information:Social Security Number:Name: __________________________Address: __________________________________________________Facility Phone Number:Nurse Aide Training Information:Trainer Name: ________________________Address: ______________________________Location: ______________________________Training Date Start: __________________MM DD YYFinish:__________________MM DD YYDate Exam was passed: ________________( ) Nurse Aide Training (Max $400)$_________( ) Competency Evaluation (Max $100)$__________Training Plan Code Number: ___________Cost of Training:Invoice Amount$___________Submitted by: ____________________________________ Date: _________________________________(Signature) MM DD YY_____________________________________(Title)