Respite Voucher - The Moore Center - moorecenter: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Client’s Name at the top of the form. This identifies who is receiving respite services.
Next, fill in the Provider’s Name and make sure to indicate who will be receiving payment by completing the 'Make Payment To' section, including their name and telephone number.
Check if the provider's address is new and fill in their complete address, including street, city, state, and zip code.
Indicate your relationship to the client by selecting one of the options provided: Biological Parent, Non-Biological Parent, Other Family, or Non-Family. If applicable, provide an explanation for 'Other Family' or 'Non-Family'.
Document the month services were used and list each day along with the corresponding number of hours worked by the provider. Remember to round hours to the nearest quarter hour.
Calculate and enter the Rate Per Hour and Total amount due based on hours worked.
Ensure both Provider’s Signature and Parent/Guardian Signature are completed before submission.

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