TIME CHANGES

Time changes may only be submitted by the Individual/Employer (person with a disability receiving services) OR their Parent/Guardian/Designated Representative (person directing services).

Time changes cannot be submitted by the Direct Support Worker and will not be accepted.

All time adjustments must have the Parent/Guardian/Designated Representative signature (name on email and from Designated Representative's email address is acceptable).
Therefore must be emailed, faxed or in person...no changes can be made over the phone.

Any changes made are only for a missing/incorrect clock in time OR clock out time.

NOTE: All fields with a RED * asterisk are required.

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Correct date and time of CLOCK IN *

TA WAIVER

AETNA & UNITED HEALTHCARE

IDD WAIVER

Time changes/corrections

Select service type Worker provided: *

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PDF
TIME CHANGE form
This pdf version can be used as alternative

Print fax or mail.
or
Use PDF Editor and email

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I certify by submitting this form that I understand the following: As the self-directing Participant/Employer or Designated Representative, I assume all responsibility of employment of Direct Support Workers (DSWs), including assuring DSW work hours are submitted to the KS Authenticare system and are within the Participant/Employer's specific Plan of Care (or Integrated Service Plan). I understand Life Patterns, Inc. policies require time changes to be submitted within 48 hours of the date needing correction to ensure timely payment, that I may only submit a maximum of five (5) time changes per month per Participant/Employer, and that hours worked that exceed the Plan of Care are not billable to my Managed Care Organization and therefore will not be billed or paid by Life Patterns, Inc.

Agree

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Application & Forms - if hired by family already

Name of Support Worker *

please use this form or email to contact:
Bailey Greene,Program Coordinator

bailey@lifepatternsks.org

(P) 785-273-7189

(F) 785-273-3816

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TBI, FE, PD WAIVER

SUNFLOWER

IDD WAIVER