Payroll-Based Journal Report

Pharma-Care, Inc
Creative Care Consulting, LLC
The Rasa Group
Payroll-Based Journal Report - Request

Please fill in the form below.
Please note that the PBJ reports are distributed monthly on the 10th Business Day after the end of the previous month. (ie. Janaury PBJ Report would be sent between the 8-10th of February)

If you do not specify Where the Monthly PBJ Report should be sent, it will be enclosed with the Monthly Invoice

Specify which Version of the Report a Printed Version will be Mailed, email, or faxed.
Attention to Contact*

PrefixFirst NameLast Name
Facility Name:*
CMS ID/NJ/PA License #
This is ID # used for submitting to CMS
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail*
SELECT ONE ONLY

Printed Report Mailed to contact aboveFAX Printed Report to Number providedPDF File of Report sent as an EMAIL AttachmentEXCEL File sent as an EMAIL Attachment
Because we are considered to be a vendor and not an employees, the Hired Date on our PBJ reports represent the Contract Date in Effect.

Since we have the flexability to assign different Consultant to your facility this becomes very confusing to CMS on your submissions, Thank You!
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Pharma-Care, IncCreative Care Consulting, LLCThe Rasa Group