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. 

TA WAIVER


AETNA & UNITED HEALTHCARE

IDD WAIVER

PDF
TIME CHANGE form

This pdf version can be used as alternative

Print fax or mail.
or
Use PDF Editor and email

MONTEZUMA


ALL MCO'S / ALL WAIVERS

​​TIME CHANGES/CORRECTIONS

please use this form or email to contact:

Sarah Laing,Program Coordinator

sarah@lifepatternsks.org

(P) 785-273-7189

​(F) 785-273-3816

please use this form or email to contact:

Anna Teichroeb,Program Coordinator

anna@lifepatternsks.org

(P) 620-846-2658

​(F) 620-846-2340

​​

 
TBI, FE, PD WAIVER


SUNFLOWER

IDD WAIVER

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

bailey@lifepatternsks.org

(P) 785-273-7189

​(F) 785-273-3816