Payroll Entry – Home Health RN, LVN, HHA, MSW, PT, OT, ST, PTA, OTA

Name*
First Last
Pay Period
Do you drive a company car?
- No
- Yes
Total visits made this payroll period
Number of visits that were out of town (0-20 MILES)
Number of visits that were out of town (20-30 MILES)
Number of visits that were out of town (30-50 MILES)
Number of visits that were out of town (50+MILES)-Gas Receipt Needed
Medical Record numbers for the out of town visits
Case conference(s) attended?
- No
- Yes
What dates? (Enter up to two dates)
In-service/training attended/performed?
- No
- Yes
What dates? (Enter up to two dates)
Enter total training hours. (TRAINING HOURS ONLY)
Did you make any Hospice consultations?*
- No
- Yes
Patient(s) MRN:*
Were you on call?
- No
- Yes - weekday
- Yes - weekend
Enter all on call dates
Did you make any on-call visits?
- No
- Yes
Number of visits
Please input patient's MRN that were seen on-call
Approved by
Were you on time for charting?
- Yes
- No
Please explain
Do you have any questions or concerns that you wish to discuss with:
- Arman Zakaryan
- David Imirian
Please enter your question or concern
Certification*
- I certify that the information entered into this form is accurate.
Name
This field is for validation purposes and should be left unchanged.

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