SHARP Quarterly Report
AK Department of Health & Social Services
Quarterly Work Report
This report form is to be completed by each SHARP practitioner's respective practice site (agency) representative. The SHARP program must verify that each participant has been delivering healthcare services at the specified practice site during the past quarter. NOTE: This form works best in Google Chrome or Firefox.
Reporting Period
*
January 1 - March 31 Report Due April 30
April 1 - June 30 Report Due July 15
July 1 - September 30 Report Due October 30
October 1 - December 31 Report Due January 31
SHARP Practitioner Name
*
First Name
Last Name
SHARP Practitioner Email
*
example@example.com
Did the practitioner work the full quarter?
*
Yes
No
If the practitioner did not work the full quarter, please indicate their start and end dates (MM-DD-YYYY)
-
Month
-
Day
Year
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End date:
-
Month
-
Day
Year
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Please indicate the number of days this practitioner was off work, including vacation time, sick days, and holidays during the quarter:
*
Does the practitioner have, or anticipate having, any other service obligation in addition to his/her SHARP contract?
*
No
Yes
If yes, briefly describe:
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Practice information
Authorized FTE:
*
Full-Time
Half-Time
Number of practice sites:
*
Primary practice site
*
Any other practice sites:
Breakout of Duties- must add to 100%
*
% of Duties
Administrative
Direct Patient Care
TOTAL
Clinician's Patient Payer Mix
*
Number of Patients
Number of Visits
(N/A for Pharmacists)
Number of Prescriptions
(Only Pharmacists)
Medicaid
Medicare
Patient Pay- Sliding Fee Scale
Patient Pay- Full Fee
No Charge or No Payment
Private Insurance
Indian Health Service
VA or other Federal Program
Other (explain below)
TOTAL
Difference between patients and visits. Your number of patients should never be higher than your number of visits. Please review your numbers above and correct it.
Explain "other" payer type if applicable
Description of Case Load- Must add up to 100%
*
% of Patients
Patients age years: 0-5
Patients age years: 6-18
Patients age years: 19-64
Patients age years: 65+
TOTAL
Settings and Type of Care - May not add up to 100%
% of Patients
Hospital
Community Health Center
By Telemedicine
Primary Care (Includes Dental & Behavioral Health)
Site that integrates Primary Care & Behavioral Health
Primary Care Medical Home Clinic
Correctional Facilities
Patients on Probation or Parole
Substance Abuse Prevention and Treatment Services
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Sign-Off
As an authorized site (agency) representative, I certify via my electronic submission that all data contained in this report are accurate and can be substantiated by a record review. • The practitioner named in this report worked as a practitioner during the stated period, at the clinic site(s) listed, and as in accordance with his/her SHARP contract. • This site (agency) used the sliding fee scale or no-pay policy for uninsured patients submitted with the sponsoring site's application.
Site Representative Printed Name
*
First Name
Last Name
Title
*
Site Representative Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Any comments or explanations for this report:
Submission Date (MM-DD-YYYY)
*
-
Month
-
Day
Year
Date Picker Icon
Submit
Click Submit below for this completed form to be sent to the practitioner's email that you included on Page 1 (if necessary, verify the address for accuracy). They will then review, and if they approve then your quarterly report will be complete.
Submit
Practitioner Sign-Off
After review of this report for accuracy, please select whether it is approved or denied, and submit.
Approved or Denied?
None selected
Approved
Denied
If you select Denied, please enter a reason into the Comment box above before submitting.
Submit
Should be Empty: