Provider Payroll Form
Revised Submission (click yes if this is a revised version of a previously submitted form)
Yes
What's your name?
Add your email for a copy to be sent to you!
example@example.com
Month
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Pay Period
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1-15th of the month
16-30/31st of the month
Employment Status
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Employee
Independent Contractor
Do you have any questions, issues or ideas that you would like us to address during our Monthly Team Meeting or in Leadership? If so, please add that information below!
Did you have any NS/Late Cancellation Fees Charged?
Please Select
Yes
No
Do any of these scenarios apply to you?
Attended one or more weekly Peer Support Meetings (Pendy's Wed. Mtg)
Completed more than 16 sessions per week($50.00/wellness stipend per week)
Attended our Monthly Team Meeting
No Show Fees
School-based Mileage
Requesting CE reimbursement
Attended Onboarding Training
Offered Onboarding Training
Administrative Hours
Want to use PTO this pay period?
Provided Clinical Supervision
Intern Sessions to report
Other
How many weekly Peer Support Meetings did you attend this pay period?
How many Many NS Fees were charged & collected on your behalf?
How many sessions did your intern complete?
Please add the names of clients who were charged for NS/Late Cancel Fees
We use this information to verify that the fees have been collected.
How many Monthly Team Meetings did you attend this pay period?
What amount of CE reimbursement are you requesting (up to $250.00/calendar year)
CE Verification
Browse Files
Drag and drop files here
Choose a file
Please upload the verification of your CE amount (may include certificate or receipt of amount paid)
Cancel
of
How many onboarding training hours did you attend this pay period?
How many weeks are you claiming mileage for? (normally will be one or two)- enter that number below. School-based Only
$25.00/week for school-based program
How many administrative hours do you have?
How many Clinical Supervision Hours did you complete?
Include clinical supervision, documentation reviews
Clinical Supervision Details
Please include the names and dates of who you provided supervision to.
How much PTO are you requesting to use?
What other amount do you want to add to this payroll?
Non-ce reimbursment, other special circumstances
Please add a brief description of the "other" amount to be included in your payroll
We use this information to verify that the fees have been collected.
Email
example@example.com
How many supervision hours did you complete
Add the names and dates of supervision provided
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