TIME CHANGES

please use this form or email to contact:

Sarah Laing,Program Coordinator

(P) 785-273-7189

(F) 785-273-3816

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

CHANGE (clock in, clock out, or both) *

RECEIVE SERVICES

ABOUT US

Correct date and time of CLOCK IN *

Select service type Worker provided: *

DEVELOPEMENT of LIFE PATTERNS, INC.

Correct date and time of CLOCK IN *

TA WAIVER

AETNA & UNITED HEALTHCARE

IDD WAIVER

Time changes/corrections

Select service type Worker provided: *

•

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

Print fax or mail.
or
Use PDF Editor and email

•

Agree

•

Application & Forms - if hired by family already

Select service type Worker provided: *

please use this form or email to contact:

Nancy Heinrichs,Program Coordinator

nancy@lifepatternsks.org

(P) 620-846-2658

(F) 620-846-2340

Reason for time change and other comments: *

Name of Support Worker *

MONTEZUMA

ALL MCO'S / ALL WAIVERS

AFTER APPROVED - How to clock in/out

Activity Codes (does not apply to Enhanced Care Services or Overnight Respite) *

Your Name (Parent/Guardian/Designated Rep.) *

•

TBI, FE, PD WAIVER

SUNFLOWER

IDD WAIVER

Application & Forms - if hired by family already

Name of Individual receiving services *

•

Your email: *

Check here to receive email updates

PAY STUBS

Reason for time change and other comments: *

Correct date and time of CLOCK OUT *

ABOUT US

General Application

Activity Codes (does not apply to Enhanced Care Services or Overnight Respite) *

•

Your Phone Number *

•

Time changes/corrections

Your Phone Number *

Correct date and time of CLOCK OUT *

General Application

•

CHANGE (clock in, clock out, or both) *

SUPPORT WORKERS

DEVELOPEMENT of LIFE PATTERNS, INC.

Activity Codes (does not apply to Enhanced Care Services or Overnight Respite) *

Apply for Services

Your Name (Parent/Guardian/Designated Rep.) *

Name of Support Worker *

•

Name of Individual receiving services *

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

bailey@lifepatternsks.org

(P) 785-273-7189

(F) 785-273-3816

Agree

AFTER APPROVED - How to clock in/out

SUPPORT WORKERS

RECEIVE SERVICES

PAY STUBS

CHANGE (clock in, clock out, or both) *

HOME

Reason for time change and other comments: *

Your email: *

Check here to receive email updates

Name of Support Worker *

Name of Individual receiving services *

Apply for Services

Your Name (Parent/Guardian/Designated Rep.) *

HOME

Your email: *

Check here to receive email updates

Correct date and time of CLOCK OUT *

Your Phone Number *

TIME CHANGES/CORRECTIONS

IMPORTANT:

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.