WORKSHEET FOR DETERMINING PAYMENT

Participant Name: _________________________________ Date: ____________

Daily Per Diem $_____ for 6 hrs per day $______

Hourly Rate $_____ for hours over or under 6 hours $______

Bath $______

Other special services (______________. _________________. _______________) $______

Transportation may fluctuate due to gasoline prices $______

Estimated Daily Total - $______

Participant Contribution - $______

Family and/or other Contribution $______

Total $ ______
Your notification for payment is sent out monthly for the days attended and services provided
as follows:
PAYER 1 PAYER 2

___________________________________ _____________________________________
(NAME) (NAME)

___________________________________ ______________________________________
(ADDRESS) (ADDRESS)

___________________________________ _____________________________________
(CITY, STATE, ZIP CODE) (CITY, STATE, ZIP CODE)

_________________________________ ______________________________________
(PHONE/EMAIL) (PHONE/EMAIL)

By signing below the participant and/or their caregiver acknowledge that they are responsible
for all unpaid fees and to provide immediate notification to the center in the event the PAYER
information changes.

Participant/Caregiver Signature: ________________________________________________

Relationship to Participant: ______________________________________________________

Program Representative: _________________________ Date:_______________________

Katie Adult Day Center Policies and Procedures Manual October 2016