1. Employer Information
Name: Wellcare Health Management, Inc. as Fiscal Intermediary for
4. Allowances takes:
5. Regular Payday:
6. Pay is:
8. Emploee Acknowledgement:
On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated pay day on the date given below. I told my employer what my primary language is.
The employee must receive a signed copy of this form. The employer must keep the original for 6 years.