Therapist Payroll Submission

Therapist Payroll Submission
Access Code*
Therapist Name*

First NameLast Name
Payroll Date*

MonthDayYear
Date
Payroll Date*
Overage of sessions (for 50% payroll, please input 0)*
Directions to run report for Oustanding Notes:

On PP, go to Reports> Tasks and Clinical> Document and Progress Note Status Report>adjust dates and select your name, set status to "Incomplete" then>Preview
I have run the PP report for outstanding notes and attest that all of my notes have been submitted.*

YESNO
If no, I have run the PP report for outstanding notes and attest that all of my notes through last pay period have been submitted. I am only missing notes from this pay period.

YESNO
If you have answered no for either question, write in how many notes are outstanding.
If you have answered no for either question, please provide expected date of completion

MonthDayYear
Date
I have submitted all reports on time (6 weeks before authorization ends), including discharge reports. I have an updated POC and report that is no more than 6 months old for all of my clients.*

YESNO
If you answered no, please indicate how many reports or POCs are outstanding
If you answered no, please provide expected date of completion.

MonthDayYear
Date
Please provide any other additional information
I certify that I have read and understand Therapy West workplace harassment, HIPPA, Child Abuse policies and attest that if I experience workplace harassment, and/or am made aware of any HIPPA or Child Abuse issues and/or if I am injured while on the job, I will notify my supervisor or one of the owners immediately.*

YESNO
To the best of my knowledge, I certify that my billing is accurate and true.*

YesNo
By initialing this document,

I certify that all of this information is accurate and true.

AND

I certify that I have not been sexually or physically harassed by a TW employee during this pay period.
Initials*
Date*

MonthDayYear
Date
Should be Empty: