OT Request Form
Max. seven (7) days OT Requests
Name
*
First Name
Last Name
Position/Role
Please Select
Medical Admin
Medical Receptionist
Medical Biller
Medical Scribe
Dental Admin
Dental Receptionist
Dental Biller
Dental Scribe
BizVA
My Ortho VA
Email Address
*
example@example.com
Reason for Overtime / Summary of OT
*
Time zone
*
Please Select
Pacific Time
Mountain Time
Central Time
Eastern Time
OT 1 Date
*
-
Month
-
Day
Year
Date
OT 1 Total Hours
*
*in decimal format (e.g., 1hr and 30mins OT = 1.5 hrs OT)
OT 2 Date
-
Month
-
Day
Year
Date
OT 2 Total Hours
*in decimal format (e.g., 1hr and 30mins OT = 1.5 hrs OT)
OT 3 Date
-
Month
-
Day
Year
Date
OT 3 Total Hours
*in decimal format (e.g., 1hr and 30mins OT = 1.5 hrs OT)
OT 4 Date
-
Month
-
Day
Year
Date
OT 4 Total Hours
OT 5 Date
-
Month
-
Day
Year
Date
OT 5 Total Hours
OT 6 Date
-
Month
-
Day
Year
Date
OT 6 Total Hours
OT 7 Date
-
Month
-
Day
Year
Date
OT 7 Total Hours
File Attachment (Optional)
Screenshot of approval from client.
Drag and drop files here
Choose a file
Cancel
of
Approver's Name
*
*Only name of client, representative, point of contact, or head of department.
Approver's Email
*
*Only email of client, representative, point of contact, or head of department.
Approver Position / Title
*
Non-Approver CC Email (Optional)
Optional CC. This person will be notified but cannot approve.
Submission Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: