2. EXHIBIT A 

   Fill this form out by the 5th of the month for payment by the end of the month:

   Upon submission it will be emailed to: fausupport@co.itasca.mn.us 

   Itasca County Health and Human Services: 1209 SE 2nd Avenue, Grand Rapids, MN 55744-3983 

    

   
   

4. Housing Support Billing (GRH Billing)

6. Facility Name:*
8. Client Name:*
9. Date of Birth:*
   Date of Birth:
11. Date of Services:*
    Date of Services: Start Date

    —

    Date of Services: End Date

    Please provide the date range of services being provided.

12. Temporary Absence:
    Temporary Absence: Start Date

    —

    Temporary Absence: End Date

    Place provide the date range of any temporary absences:

14. Number of Absent Nights?
15. Year to date total absent days at your facility?
17. Name of person completing the form:*
18. Phone number of person completing the form:*
19. Email of person completing the form:
21. Reason for Temporary Absence:
23. Authorization for Placement:

    Reason for Placement:

25. Authorization of Services:

    Services Provided:

29. AGENCY USE:

31. Date Received:
32. Amount Paid:
34. Date Processed:
36. Preauthorized leave days:
38. Approved by:
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field