Quarterly Work Report

Quarterly Work Report

Quarter 3 - 06/29/2025 - 09/27/2025
Welcome to the Quarterly Work Report

Please complete and submit the Quarterly Work Report with enough time for the professional to review and approve no later than October 31.

This report records healthcare professionals' service hours, work locations, and patient care activities.

Once submitted, the QWR is routed to the healthcare professional for review. If approved, it is submitted to program staff for processing. If denied, the professional must provide a comment explaining the discrepancy, and the form will be returned for revision and resubmission.

If you have questions during this process, contact program staff at oha.wi.info@alaska.gov.
Welcome to the Quarterly Work Report

Please review and certify the Quarterly Work Report submitted by your employer.

The report includes service hours, telehealth use, and direct patient care activities. If the information is correct, approve the report for submission to program staff for processing. If incorrect, provide a reason for denial, and the form will be returned to the employer for revisions.

If you have questions during this process, contact program staff at oha.wi.info@alaska.gov.
Quarterly Work Report

{professionalsName} did not approve of the following QWR Quarterly Work Report for the following reason(s):

{theQwr}

if you have any questions regarding the decision or need further clarification, please reach out to {professionalsName} directly.

Please review the reasons provided and update as necessary. Once adjustments are made, resubmit the form for review.

If you have questions during this process, contact program staff at oha.wi.info@alaska.gov.
Please click below to edit.

I would like to edit this QWR
Quarterly Work Report

Your Quarterly Work Report has been resubmitted by your employer.

If the information is correct, approve the report for submission to program staff for processing. If incorrect, provide a reason for not approving, and the form will be returned to the employer for revisions.

If you have questions during this process, contact program staff at oha.wi.info@alaska.gov.
Please click below to review.

I would like to review my QWR

Professional Information
Professional's Name*

First NameLast Name
Professional's Email*
Discipline*
Tier*
Position Title*
Service Level*

Full-TimeHalf-Time
Employer Information
Employer Name*
Employer Representative Name*

First NameLast Name
Phone Number*
Employer Rep
Email*
Employer Rep

Work Hours
Please ensure all entries reflect actual, verifiable service data.

All fields must be completed, enter zero where applicable.

Do not use estimates, averages, or projected hours.

For each week of the quarter complete the following:
- Days Worked: Total number of calendar days work was performed, even if just a portion of the day.
- Total Hours Worked: Total of actual hours worked for that week, limited to no more than 12-hours in any rolling 24-hour period.
- Direct Patient Care Hours: The hours dedicated to direct patient care, both in-person and telehealth. This includes case consultation, care coordination, case management, charting, medication management, follow-ups, and patient communications.
- Telehealth Hours: Portion of Direct Patient Care Hours provided via telehealth.
Use the comments section to provide any clarifications, or additional information as needed.

Work Hours*

	Days Worked	Total Hours Worked	Direct Patient Care Hours	Telehealth Hours
06/29/25 - 07/05/25
07/06/25 - 07/12/25
07/13/25 - 07/19/25
07/20/25 - 07/26/25
07/27/25 - 08/02/25
08/03/25 - 08/09/25
08/10/25 - 08/16/25
08/17/25 - 08/23/25
08/24/25 - 08/30/25
08/31/25 - 09/06/25
09/07/25 - 09/13/25
09/14/25 - 09/20/25
09/21/25 - 09/27/25

Comments:
N/AWork hours
Site Summary

For each site the professional provided services for the quarter, enter the total number of days and hours worked.

Payer Mix
All fields must be completed, enter zero where applicable. Do not use estimates or projections

For each payer typer, complete the following:
- Total Patients: Total number of unique patients during the quarter.
- Total Visits: Total number of visits, including repeat visits. For pharmacists enter the total number of prescriptions filled.
If a patient is covered by multiple payer types, record them under their primary payer only.

Use the comments section to provide any clarifications, or additional information as needed.

Payer Mix*

	Total Patients	Total Visits
Indian Health Services
Medicaid
Medicare
Private Insurance
Self-Pay - Full Fee
Self-Pay - No Fee
Self-Pay - Sliding Fee Scale
VA/Tricare
All Others

Comments:
N/APayer Mix

Caseload
All fields must be completed, enter zero where applicable. Do not use estimates or projections

For each age group, enter the number of unique patients, broken down by gender.

If a patient's age changes over the quarter, record them in the group where they received the majority of care.

Use the comments section to provide any clarifications, or additional information as needed.

Caseload*

	Male	Female	Other
0 - 1 years
2 - 5 years
6 - 18 years
19 - 64 years
65 - 74 years
75+ years
Unreported

Comments:
N/ACaseload

Submission Page
You must agree to the following, to submit this QWR

I certify that the information provided in this report is accurate and complete to the best of my knowledge.
You must agree to the following, to submit this QWR

I certify that the information provided in this report is accurate and complete to the best of my knowledge.
Representative

First NameLast Name
Date

YearMonthDay
Do you approve this QWR for final submission?

YesNo
The QWR was not approved for the following reason(s):
You must agree to the following, to submit this QWR

I certify that I have reviewed this report and confirm that the information is accurate and reflects my activities for the quarter.
Do you approve this QWR for final submission?

YesNo
The QWR was not approved for the following reason(s):
You must agree to the following, to submit this QWR

I certify that I have reviewed this report and confirm that the information is accurate and reflects my activities for the quarter.
First Name
Last Name
Date

YearMonthDay
Submission Stage
Should be Empty:

Quarterly Work Report

Welcome to the Quarterly Work Report

Welcome to the Quarterly Work Report

Quarterly Work Report

Quarterly Work Report

Professional Information

Employer Information

Work Hours

Site Summary

Payer Mix

Caseload

Submission Page