Physician Name (First Last)
Date (Activity 1)
-
Month
-
Day
Year
Entry 1
Hours Spent (Activity 1)
Entry 1
Description of Services (Activity 1)
Entry 1
Date (Activity 2)
-
Month
-
Day
Year
Entry 2
Hours Spent (Activity 2)
Entry 2
Description of Services (Activity 2)
Entry 2
Date (Activity 3)
-
Month
-
Day
Year
Entry 3
Hours Spent (Activity 3)
Entry 3
Description of Services (Activity 3)
Entry 3
Cost Center
1100-20004
GL Code
665011
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