Fiscal Intermediary PDF File Access

    

This timesheet can be completed using Adobe Reader and saved to your computer.  Then each payroll period, review and make any changes to the hours and totals, correct the payroll period beginning and ending dates, print the form, complete the PCA and consumer/surrogate signatures and fax the form to us using the telephone number on the top of the timesheet..

 

NEW!     FILL-IN TIMESHEET    NEW!