MILEAGE – TIMECARD RECORD

MILEAGE - TIMECARD RECORD

DISCIPLINE(circle one):

In signing, I am certifying that I have personally completed this timesheet and the hours are accurate.

Fax 1-888-681-9011 or deliver to office. DEADLINES: end of day on the 1st and 16th. Note: your paycheck will be delayed if your time sheet is not received by the above dates.

PT PTA OT COTA ST RN LPN HHA PCA
Date Patient
initials (from)		 Patient
initials (to)		 Start
Miles		 End
Miles		 Total
Miles		 Activity Code
(and Description when required)		 Start
Time		 End
Time		 Total
Hours		 Patient Signature:
(ONLY REQUIRED FOR TIME ENTERIES)
ACTIVITY CODES:
Office use only:

01-reg. visit(60+miles from/to office or pt. approved
02-initial eval/DC eval/&DC Oasis
03-RE-eval
04-other
07-Attempted visit(does not answer door)
10-Inservices
11-meetings(in office or per request by phone)