Service Date

mm/dd/yyTime in Time Out Time In Time Out Total

Hours

Sunday AMPM

AMPM

AMPM

AMPM

Monday AMPM

AMPM

AMPM

AMPM

Tuesday AMPM

AMPM

AMPM

AMPM

Wednesday AMPM

AMPM

AMPM

AMPM

Thursday AMPM

AMPM

AMPM

AMPM

Friday AMPM

AMPM

AMPM

AMPM

Saturday AMPM

AMPM

AMPM

AMPM

Payroll Week One

WeeklyTotal

Service Date

mm/dd/yyTime in Time Out Time In Time Out Total

Hours

Sunday AMPM

AMPM

AMPM

AMPM

Monday AMPM

AMPM

AMPM

AMPM

Tuesday AMPM

AMPM

AMPM

AMPM

Wednesday AMPM

AMPM

AMPM

AMPM

Thursday AMPM

AMPM

AMPM

AMPM

Friday AMPM

AMPM

AMPM

AMPM

Saturday AMPM

AMPM

AMPM

AMPM

Payroll Week Two

WeeklyTotal

EMPLOYEE TIMESHEET

NOTE:Timesheets MUST be signed and dated AFTER the work is completed. Advance time sheets will not be accepted./Hojas de tiempo tienenque ser firmadas despues que el trabajo sea completado. Hojas de tiempo entregadas antes de que el trabajo sea completado seran rechazadas.

Employee Signature/Firma Empleado Date Employer or Designated Representative Signature/Firma del Empleador Date

Employee/Employer: I certify that the work hours listed above are accurate, that the services provided are in accordance with the current tasks authorized and that ser-vices were NOT provided while the Participant was in a hospital, nursing home, or other Medicaid‐reimbursed healthcare facility. I understand that falsification of this time sheet is considered Medicaid Fraud,and may result in dismissal from the program and criminal prosecution./Certifico que las horas de trabajo mencionadas anteriormente son precisas, y que los servicios provenidos son de acuerdo con las tareas autorizadas. Certifico que los servicios no fueron provenidos mientras que el participante estaba en un hospital, asilo de ancianos, o otro centro de atencion medica reembolsado por Medicaid. Entiendo que la falsificacion de esta hoja de tiempo se considerará fraude de Medicaid y puede resultar en la expulsion del programa y enjuicamento penal.

Participant Name (Client)

Time sheet due date: Time sheets can be faxed, emailed, or droppedoff and are due the Monday after the pay period worked. If mailed, theymust be postmarked by Monday after the pay period worked. Refer to

timesheet calendar provided. Late time sheets may result in late pay.

Service Provider Name (Employee)

Employer Name (If different than Participant)

Select One Service:

PAS HAB Protective Respite Other

Select One Program: DADS: CLASS MDCP PCS PHC CMPAS Other

MCO: SPW/CBA NWP/PHC

The participant was hospitalized this pay period on the following days ___________________________________.

Check if your employee lives withyou and is exempt from overtime pay

Check if your employee lives withyou and is exempt from overtime pay

Email: cdstimesheets@outreachhealth.com or fax: 866.703.1130 or 888.703.1416

Medicaid Number:

Section 3:Record the hours

worked for the day.Select AM or PM for time in and time out.

Section 4: Total the hours

worked each day.

Section 5: Total weekly hours will be calculated

automatically. If not filled out electroni-cally, please add total hours here.

Section 2:Select one

program and one service.

Frank Sinatra Mark Jacobs

Section 9:Both the employer or designated

representative andemployee must sign for the work time to be paid.

Section 10:Timesheets MUST be signed and

dated AFTER the work is completed.Advance time sheets will not be accepted.

Employee Timesheet Instructions and Sample

Section 8:Record dates if the

participant was admitted to a facility.

Remember an employee cannot work these days.

1/17/2016 - 1/18/2016

Section 6:Check if applies

Section 1:Print service provider name, participant name, Medicaid

number and employer name if different from Participant

(Client).