Please Only Fax to: 905-771-2764 Non-use of Telephony Home Visit Confirmation Please have your client or Substitute Decision Maker sign verifying your visit start and end time.
A separate sheet MUST be used for each client, and faxed in the day of the visit. Please print clearly; all lines must be filled out.
DATE: _____MONDAY, JULY 10, 2011
Enter the Date as shown!
Employee Name: _ __HARRY POTTER_____________ Employee Number: _9999_______________________
CLIENT NAME: ______JANE DOE _____________
Your name and Emp. # has to be entered
GOLDCARE # (if known) ______12345_______________
If you have the Client ID than write it in!
Clients name has to be entered in.
CLIENT ADDRESS: ___________________________________________________________________________________________________________________________
Accurate Start Times are important Visit Start Time: _______16:30____________________________
Accurate End Times are important for payroll. Visit End Time: ————17:30—————
Always insure that Client writes his/her signature.
Jane Doe___________________________________
Client or SDM Signature: _____
Visit Start Time:_____________________________________ Visit End Time: ——————————————————————
IF you visit the Client or SDM Signature: same client __________________________________________________________________________________________________________________________ more than once per day than Visit Start Time: _____________________________________ Visit End Time: —————————————————————— you must input them as separate Client or SDM Signature: entries. __________________________________________________________________________________________________________________________
REASON FOR NON-USE OF TELEPHONY VISIT CONFIRMATION: ____________Client’s phone was not working.________________________
A reason must always be stated on the Time Sheet especially if Client is set up for Telephony confirmations.
Examples of Time Sheets that are being sent in incorrectly. Please insure that you are checking the settings on you Fax Machine. Adjust the contrast so it does not come out black. When faxing adjust the paper so that it does not twist in progress. If you’re unsure if your fax came through than contact Kiran X3243 to see if she has received it.
FAX to-905-771-2764 Shared Care--Long Term Care--Group Home Faxes ONLY
STAFF SIGN-IN/OUT & CLIENT SIGNATURE
Name of Home:
Delmanor Retirement Home
This Time Sheet should only be used when you are working in Shared Care Facilities.
Please insure that the Facility name is listed.
(please use 1 fax sheet per Home)
Address of Home:
123 Blue Jay Blvd. Toronto, ON
In put the address for the facility.
Staff Name + Emp. #
Always make sure that your write in your name and employee number. Blanks are unacceptable.
HARRY POTTER EMP: 9999 Please Print
Date July 10, 2011
Client Name
please print
Time In
Time Out
Jane Doe
1030
1130
John Doe
1130
1230
Molly Doe
1300
1315
Date has to be entered on the Time Sheet, if you visit two days a week, insure that every row has a separate date to insure accuracy when sent to PHCS for processing.
Each name has to be entered in a separate row.
Client’s Signature
Client Goldcare #
1234 THIS IS MANDATORY. PLEASE CHECK YOU TIME SHEET BEFORE SUBMITTING THAT CLIENT SIGNATURE IS THERE.
For every client visited a TIME IN AND TIME OUT entry needs to be written in the appropriate fields. Blanks are unacceptable and overall time is not valid ex. 8am5pm. That does not tell us which client was serviced at a specific time.
The More Client details we have the faster we can locate the information on your schedule and process for payroll.
Keep this example for your reference in your privacy binder
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