NYS OPWDD Self Direction Supported Employment Employee Billing Sheet/Daily Service Record Fiscal Intermediary (FI) Agency: MultiService Provider ID Participant's Medicaid CIN: Employee's Name: Billing Sheet for Period Ending:

INDEPENDENT SUPPORT SERVICES, INC. 03880206 Participant's Name: Employee's Title: SEMP Staff Primary Service Location:

CSS-02a

You must place your initials in the “Initials” box for each date a service was provided. This is your attestation that you provided a service was provided on that day. Billable Hours Worked Day

Date: Mo/Day

Start Time

End Time

Non-Billable Hours Worked Start Time

End Time

Total Billable Hrs Per Day

Total Non-Billable Hrs Per Day

Initials

Total Billable Hrs Per Day

Total Non-Billable Hrs Per Day

Initials

Mon Tues Wed Thurs Fri Sat Sun Total billable and non-billable hours worked this week: Total hours worked this week:

Additional Comments: Billable Hours Worked Day

Date: Mo/Day

Start Time

End Time

Non-Billable Hours Worked Start Time

End Time

Mon Tues Wed Thurs Fri Sat Sun Total billable and non-billable hours worked this week: Total hours worked this week:

Total hours worked this pay period:

Total billable hours worked this pay period:

Additional Comments:

Total non-billable hours worked this pay period:

Check here if there is a shared staff arrangement (more than 1 person served at same time) □ Identify other persons served:

***Signing and submitting false information may lead to a charge of Medicaid fraud.*** Signature of Employee:

Initials:

Signature of Participant/Representative:

Date: Date:

Participant: Original to FI

Revised 9/25/14

For FI Use Only ----- Payroll Authorization

(FI Initials)

Non-Billable activities include: 1. When Supported Employment services are provided at a Participant's home instead of the work site. 2. When multiple Supported Employment services are provided on the same day. 3. When you, as a staff member, are attending outside training sesions 4. When you, as a staff member, are completing documentation