Therapist Payroll Submission

Access Code*

Please select applicable pay period *

Therapist Name*

First NameLast Name

Payroll Date

Date

Payroll Date*

Overage of sessions (for 50% payroll, please input 0)

PER DIEM STAFF: Please enter sessions completed during this pay period

Rows	Child's Name	DOS	Hours
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Total hours for per diem staff

Student double bookings, if applicable (i.e. student is treating at the same time). Please note that double bookings can NOT be done with TWISPP:

Rows	Child's Name	DOS	Hours
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Total hours seen by student

Directions to run report for Oustanding Notes:

On PP, go to Reports> Tasks and Clinical> Document and Progress Note Status Report>adjust dates and select your name, set status to "Incomplete" then>Preview

I have run the PP report for outstanding notes and attest that all of my notes have been submitted.*

YESNO

If no, I have run the PP report for outstanding notes and attest that all of my notes through last pay period have been submitted. I am only missing notes from this pay period.

YESNO

If you have answered no for either question, write in how many notes are outstanding.

If you have answered no for either question, please provide expected date of completion

Date

I have submitted all reports on time (6 weeks before authorization ends), including discharge reports. I have an updated POC and report that is no more than 6 months old for all of my clients.*

YESNO

If you answered no, please indicate how many reports or POCs are outstanding

If you answered no, please provide expected date of completion.

Date

Please provide any other additional information

I certify that I have read and understand Therapy West workplace harassment, HIPPA, Child Abuse policies and attest that if I experience workplace harassment, and/or am made aware of any HIPPA or Child Abuse issues and/or if I am injured while on the job, I will notify my supervisor or one of the owners immediately.*

YESNO

To the best of my knowledge, I certify that my billing is accurate and true.*

YesNo

By initialing this document,

I certify that all of this information is accurate and true.

AND

I certify that I have not been sexually or physically harassed by a TW employee during this pay period.

Initials*

Date*

Date