BST

Invoice for Independent Health Care Providers

Mail Address: Genworth Life & Annuity Insurance Company, Insured’s Name: Lili S Yang
____________________________
Genworth Life Insurance Company,
Genworth Life Insurance Company† Policy Number: AAA5011817
____________________________
Attn: LTCI Claims Claim Number: A313068
____________________________
P.O. Box 40007, Lynchburg, VA 24506-9939
Fax Number: 888 557.5526
Phone Number: 800 876.4582 Caregiver’s Name: ____________________________
Visit Us Online: www.genworth.com/login.html (PLEASE PRINT)

Tasks Performed
(Key shown below)
Shift Shift Shift Shift Location Location

AM

HM
CO
BA
DR

TO
EA

CS
TR
Date Hours
Start1 End1 Rate Charge In2 Out2

Tasks Key
Total Total BA (Bathing)
Hours: Charge: DR (Dressing)
TR (Transferring)
(Transportation for medically necessary, life- CO (Continence)
Miles Mileage sustaining or safety functions in service to TO (Toileting)
Amount: the Insured. The normal rate approved is the EA (Eating)
Driven: IRS medical rate ($0.19/mile). Please AM (Ambulation)
contact us for exceptions to this process.) CS (Cognitive Supervision)
HM (Homemaker Services)
Total Invoice Charge: (Total Charge + Mileage Amount)
Fraud Notice:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
Signature of Insured or Authorized Representative: _________________________________________ Date: __________
Signature of Caregiver: _______________________________________________________________ Date: __________
†Only Genworth Life Insurance Company of New York is licensed in New York.

¹ Indicate AM or PM for “Shift Start” and “Shift End”

² Location In/Out refers to where the Caregiver is at the start and end of each shift (i.e., Insured’s Home, Caregiver’s Home, Doctor, etc.) (Rev 09/2016)