Missed Punch Report with Tasks

Please complete this form within 24 hours of the visit and make sure your documentation is complete including A CLIENT SIGNATURE.

If ANY of the required elements are missing, your submission will not be approved and a manager will need to validate the details of the visit with the client. This may delay payment of the visit.

Do not submit this form before the end of the shift.

Your Name*

First NameLast Name

Your Email:*

This form is subject to approval. You will receive an email when your timesheet is approved or denied. If your submission is denied you will receive notification and opportunity to resubmit by email.

Client Name

First NameLast Name

Client's FIRST Name ONLY*

Work Date*

Date

Timesheet Week Ending*

Date

Shift Start*

Hour Minutes

AM/PM Option

Shift End*

Hour Minutes

AM/PM Option

Please punch out closer to the Shift End or change the Shift End time. Forms submitted more than 5 minutes before the Shift End will be denied.

Current Time

Date

Hour MinutesAM/PM Option

calculation

Task List*

	Task
115 - Meal Preparation
116 - Housework/Chores
118 - Managing Medications
119 - Shopping
120 - Transportation
122 - Hygeine
123 - Dressing Upper
124 - Dressing Lower
125 - Locomotion
126 - Transfer
127 - Toilet Use
128 - Bed Mobility
129 - Eating
130 - Bladder Incontinence
131 - Bowel Incontinence
132 - Personal Care
134 - Bathing
135 - Bathing (Shower)

Notes*

All missed punches must be verified by one of the following methods

Client Signature and acknowledgement (Preferred)
Client Voice Verification (only to be used for clients who are physically unable to sign) (See below)
Signature verification and acknowledgement by a third party at the residence (only to be used for clients with congntive deficiencies who are unable to verify)

Forms submitted without the required verification will DENIED and verified by a manager. If we are not able to verify the timesheet it will not be paid.

Employee Signature (Must be Legible)*

Clear

Certification: I certify that the information entered is true and correct. I understand that falsification or misrepresentation of this timesheet is Medicaid Fraud and it is a CRIME.*

Employee Acknowledgement

Client Signature

Clear

Certification: I certify that the information entered is true and correct. I understand that falsification or misrepresentation of this timesheet is Medicaid Fraud and it is a CRIME.

Client Acknowledgement (this MUST be selected by the CLIENT)

Client Voice Verification

Click Here to enter third party verification

Third Party Signature : I verify the details entered on this form to be true and correct as witnessed by me.

Clear

Certification: I certify that the information entered is true and correct. I understand that falsification or misrepresentation of this timesheet is Medicaid Fraud and it is a CRIME.

Third Party Acknowledgement

Please enter your relationship to the client

Please enter your name

First NameLast Name

Verification Status:

Client Signature Missing - details of this visit were verbally verified by the client or other authorized representativeClient is unable to sign - details of the visit were verbally verified by the client or other authorized representativeClient Signature is not acceptable - details of the visit were verbally verified by the client or other authorized representativeThe details of this visit do not match the details provided by the client or other authorized representative

Name of person providing verbal verification of visit details

First NameLast Name

Name of manager taking verbal verification of visit details

First NameLast Name

Note

Missed Punch Form

Missed Punch Form

Manager's Validation of Visit