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INDEPENDENT PROVIDER PAYMENT REQUEST (Do not use this form if you are a Née nah Joint School District employee or substitute)Independent Providers Name: Address: City/State/Zip: Date(s) of Service:

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How to fill out independent provider payment request

01

To fill out an independent provider payment request, follow these steps:

02

Start by entering your name, address, phone number, and email address in the designated sections.

03

Provide the name and contact information of your employer or agency.

04

Indicate the dates of service for which you are requesting payment.

05

Specify the type of services provided and the corresponding billing codes, if applicable.

06

Include the total number of hours worked or units provided for each service.

07

Calculate the total amount owed by multiplying the hours/units by the agreed-upon rate.

08

Attach any necessary supporting documents, such as invoices or service logs.

09

Sign and date the payment request form.

10

Submit the completed form and supporting documents to the appropriate recipient, as specified by your employer or agency.

Who needs independent provider payment request?

01

Independent providers who offer services such as caregiving, tutoring, freelance work, or any other type of contracted service may need to fill out an independent provider payment request. This request is typically used to request payment for services rendered to a client or employer. Independent providers who are not part of a traditional payroll system and are responsible for invoicing and collecting payment on their own often need to use this type of payment request.

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