Physician Recruitment Payment Validation Form

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Physician Recruitment Payment Validation
Physician Name:
______________________________
Group Name: ____________________________________________________
Contract #:
______________________________
Vendor #: ______________________________________________________
Facility Name:
______________________________
Facility #:_______________________________________________________
Department Name: ______________________________
GL #: __________________________________________________________
Describe Type of Service: _______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Contract Effective Date: _______________________Contract Termination Date: ______________________Current Payment: $
-
Total Compensation Cap: ______________________Compensation Term to Date: $
-
(includes this payment)
Other Specific/Individual Payment Caps: ____________________________________________________________________________________
Other Key Terms: _______________________________________________________________________________________________________
NOTE: ALL REQUIREMENTS MUST BE MET FOR PAYMENT
Item
Issue – Physician
Complete
Comments/Deficiency
1.
Is the applicable contract signed and in effect?
Yes
No
2.
Does the reimbursement request include a completed, legible
detailed revenue & expense report (Monthly Reporting I Payment
Yes
No
Summary) to validate the legitimacy of reported amounts from the
Physician or the physician’s agent
3.
Is the supporting documentation for cash receipts and individual
expense items attached to the Monthly Reporting I Payment
Yes
No
Summary?
4.
Do the Monthly Reporting / Payment Summary totals appear
reasonable compared to prior reports, individual totals or
Yes
No
projections?
5.
Was the Monthly Reporting / Payment Summary submitted with
th
contract items (i.e. by the 20
day of the following month)?
Yes
No
6.
Does the total of payments made (including this request) cause
payments to exceed payment caps stipulated in the contract?
A. Total Allowable Expenses
Yes
No
B. Total Allowable Compensation
C. Individual line- item expense caps
Item
Issue – Other Recruitment Contracts
Complete
Comments/Deficiency
1.
Is the applicable contract signed and in effect?
Yes
No
2.
Does the amount requested for payment agree to the contracted
Yes
No
amount?
3.
If reimbursing for moving expenses and/or student loans, is
Yes
No
supporting documentation attached to check request?
If above is complete and compliant: Certify with your signature
below and forward this form to Accounts Payable to process for
Yes
payment along with check request
If above is not complete or incorrect; return to the Contract
No
Manager for follow-up / correction
I certify that I have reviewed all of the above information relative to this payment request including the Monthly Reporting / Payment Summary
and supporting documentation. All of the information provided is accurate and consistent with the terms of the signed Physician Recruitment
Agreement
__________________________________________________________________
Date: ___________________
Responsible Manager / Director Signature
I certify that I have reviewed all of the above information and have made any necessary resulting accounting entries.
__________________________________________________________________
Date: ___________________
Responsible Contract Manager / Designee Signature (if applicable)
I have reviewed all of the above information. I concur that this is a properly documented payment request. AP may process for payment.
__________________________________________________________________
Date: __________________
VP or Officer Signature
__________________________________________________________________
Date: __________________
Compliance Officer Signature
I have reviewed all of the above information. I concur that this is a properly documented payment request. AP may process for payment.
NOTE: THIS FORM MUST BE SIGNED BY THE RESPONSIBLE MANAGER / DEPARTMENT ADMINISTRATIVE DIRECTOR AND INCLUDED IN THE CHECK REQUEST
PACKET TO BE FORWARDED TO COMPLIANCE FOR PROCESSING.
Physician Recruitment Payment Validation
Physician Name:
______________________________
Group Name: ____________________________________________________
Contract #:
______________________________
Vendor #: ______________________________________________________
Facility Name:
______________________________
Facility #:_______________________________________________________
Department Name: ______________________________
GL #: __________________________________________________________
Describe Type of Service: _______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Contract Effective Date: _______________________Contract Termination Date: ______________________Current Payment: $
-
Total Compensation Cap: ______________________Compensation Term to Date: $
-
(includes this payment)
Other Specific/Individual Payment Caps: ____________________________________________________________________________________
Other Key Terms: _______________________________________________________________________________________________________
NOTE: ALL REQUIREMENTS MUST BE MET FOR PAYMENT
Item
Issue – Physician
Complete
Comments/Deficiency
1.
Is the applicable contract signed and in effect?
Yes
No
2.
Does the reimbursement request include a completed, legible
detailed revenue & expense report (Monthly Reporting I Payment
Yes
No
Summary) to validate the legitimacy of reported amounts from the
Physician or the physician’s agent
3.
Is the supporting documentation for cash receipts and individual
expense items attached to the Monthly Reporting I Payment
Yes
No
Summary?
4.
Do the Monthly Reporting / Payment Summary totals appear
reasonable compared to prior reports, individual totals or
Yes
No
projections?
5.
Was the Monthly Reporting / Payment Summary submitted with
th
contract items (i.e. by the 20
day of the following month)?
Yes
No
6.
Does the total of payments made (including this request) cause
payments to exceed payment caps stipulated in the contract?
A. Total Allowable Expenses
Yes
No
B. Total Allowable Compensation
C. Individual line- item expense caps
Item
Issue – Other Recruitment Contracts
Complete
Comments/Deficiency
1.
Is the applicable contract signed and in effect?
Yes
No
2.
Does the amount requested for payment agree to the contracted
Yes
No
amount?
3.
If reimbursing for moving expenses and/or student loans, is
Yes
No
supporting documentation attached to check request?
If above is complete and compliant: Certify with your signature
below and forward this form to Accounts Payable to process for
Yes
payment along with check request
If above is not complete or incorrect; return to the Contract
No
Manager for follow-up / correction
I certify that I have reviewed all of the above information relative to this payment request including the Monthly Reporting / Payment Summary
and supporting documentation. All of the information provided is accurate and consistent with the terms of the signed Physician Recruitment
Agreement
__________________________________________________________________
Date: ___________________
Responsible Manager / Director Signature
I certify that I have reviewed all of the above information and have made any necessary resulting accounting entries.
__________________________________________________________________
Date: ___________________
Responsible Contract Manager / Designee Signature (if applicable)
I have reviewed all of the above information. I concur that this is a properly documented payment request. AP may process for payment.
__________________________________________________________________
Date: __________________
VP or Officer Signature
__________________________________________________________________
Date: __________________
Compliance Officer Signature
I have reviewed all of the above information. I concur that this is a properly documented payment request. AP may process for payment.
NOTE: THIS FORM MUST BE SIGNED BY THE RESPONSIBLE MANAGER / DEPARTMENT ADMINISTRATIVE DIRECTOR AND INCLUDED IN THE CHECK REQUEST
PACKET TO BE FORWARDED TO COMPLIANCE FOR PROCESSING.
Physician Service Agreement Payment Validation
Physician:
Vendor #
Contract #:
Facility #
Facility Name:
Department #
Department Name:
GL #:
escribe Type of Service: __________________________________________________________________________________________
D
Contract Effective Date: _______________________________________________ Contract Termination Date: _____________________
Total Compensation Cap:______________________________________________ Compensation Term to Date: ____________________
Other Specific/Individual Payment Caps: ______________________________________________________________________________
Other Key Terms: ________________________________________________________________________________________________
NOTE: ALL REQUIREMENTS MUST BE MET FOR PAYMENT
Item
Issue – Other Recruitment Contracts
Complete
Comments/Deficiency
1.
Is the applicable contract signed and in effect?
Yes
No
2.
Does the check request packet include appropriate supporting
documentation for payment amount?
Yes
No
3.
Does the payment amount agree to the outlined contract?
Yes
No
4.
Does the amount and purpose of this payment appear reasonable?
Yes
No
5.
Are there any contractual reconciliations or rate adjustments (CPI,
etc) that need to be made with payment?
Yes
No
If above is complete and compliant: Certify with your signature
below and forward this form to Accounts Payable to process for
Yes
payment along with check request.
If above is not complete or incorrect; return to the Contract
Manager for follow-up / correction.
No
I certify that I have reviewed all of the above information relative to this payment request including the Monthly Activity Statements and
supporting documentation. All of the information provided is accurate and consistent with the terms of the signed Physicians Services
Agreement.
__________________________________________________________________
Date: ________________________
Department Manager / Director Signature
__________________________________________________________________
Date: _______________________
Responsible Manager / Designee Signature (if applicable)
__________________________________________________________________
Date: _______________________
VP or Compliance Officer Signature
I have reviewed all of the above information. I concur that this is a properly documented payment request. AP may process for payment.
Compliance Officer Signature: ________________________________________
Date: _____________________
NOTE: THIS FORM MUST BE SIGNED BY THE RESPONSIBLE MANAGER / DEPARTMENT ADMINISTRATIVE DIRECTOR AND INCLUDED IN THE CHECK REQUEST
PACKET TO BE FORWARDED TO COMPLIANCE FOR PROCESSING.
Medical Director Payment Validation
Physician:
Vendor #
Contract #:
Facility #
Facility Name:
Department #
Department Name:
GL #:
Describe Type of Service: _____________________________________________ Current Payment:
$
____________ -
Contract Effective Date: _______________________________________________ Contract Termination Date: __________________
Total Compensation Cap:
Compensation Term to Date:
$
___________________________________-
$
-
____
Includes this payment
Other Specific/Individual Payment Caps: _____________________________________________________________________________
Other Key Terms: ________________________________________________________________________________________________
NOTE: ALL REQUIREMENTS MUST BE MET FOR PAYMENT
Item
Issue – Other Recruitment Contracts
Complete
Comments/Deficiency
1.
Is the applicable contract signed and in effect?
Yes
No
2.
Does the check request packet include a completed, legible
Medical Director Monthly Time Sheet form the Medical
Yes
No
Director?
3.
Is the Medical Director Monthly Time Sheet form?
Yes
No
4.
Is the number of hours of services reported by the Medical
Director consistent with the above contract?
Yes
No
5.
Are the services reported by the Medical Director consistent with
the services indentified in the contract? (See attached Exhibit A.)
Yes
No
6.
Does the payment fall within any weekly, monthly or annual cap
stipulated in the contract relative to hours and/or compensation?
Yes
No
7.
Are there any contractual reconciliations or rate adjustments (CIP,
etc. that need to be made with the payment?
Yes
No
If above is complete and compliant: Certify with your signature
below and forward this form to Accounts Payable to process for
Yes
payment along with check request.
If above is not complete or incorrect; return to the Contract
Manager for follow-up / correction.
No
I certify that I have reviewed all of the above information relative to this payment request including the Monthly Activity Statements and
supporting documentation. All of the information provided is accurate and consistent with the terms of the signed Physician Services
Agreement.
__________________________________________________________________
Date: _____________________
Responsible Manager / Designee Signature (if applicable)
__________________________________________________________________
Date: ______________________
VP or Officer Signature
I have reviewed all of the above information. I concur that this is a properly documented payment request. AP may process for payment.
Compliance Officer Signature __________________________________________
Date: ____________________
NOTE: THIS FORM MUST BE SIGNED BY THE RESPONSIBLE MANAGER / DEPARTMENT ADMINISTRATIVE DIRECTOR AND
INCLUDED IN THE CHECK REQUEST PACKET TO BE FORWARDED TO ADMINISTRATION FOR PROCESSING.
MEDICAL DIRECTOR MONTHLY TIME SHEET & PAYMENT VALIDATION
IMPORTANT NOTICE: Complete monthly, include all requested information and forward to the Responsible Manager for
validation and processing.
No compensation will be paid until the Monthly Time Sheet for that period is submitted and validated as complete.
__________________________________
__ __ /__ __/__ __ __ __ to __ __ /__ __/__ __ __ __
Medical Director Name
* Attach Exhibit A (the Description of Services) from your Contract to the Monthly Time Sheet and include the appropriate
activity number from the Description of Services in the space set forth below.
Activity Time
Date
* Activity #
Comments/Description/Results Achieved
(Specify: Hours or Per Diem)
Contractual hours _______ per week / month / other: _____________ (indicate time period)
Total Time this Report Period of Hours / Per Diem
Rate per Hour / Per Diem
Total Amount Due
List of Hospital Approved staffing, space, equipment, marketing, goals or results (if any) under this payment:
I certify that the above information is a true and accurate recording of the time spent on the duties required as Medical Director.
_____________________________________________________
Date:_______________________
Medical Director Signature:
_____________________________________________________
Date:_______________________
Responsible Manager / Director Signature
PAYROLL
CHECK REQUEST FOR EMPLOYED PHYSICIANS
(Not for expense reimbursement)
Issue Payroll Check to:
TOTAL CHECK AMOUNT
$_____________________________________________
Facility #
Dept #
ACCT/Exp#
Amount
Facility
Describe Type of Service Payment is for:
Employment Contract Effective Date:
Contract Termination Date:
Total Compensation Cap: $
Compensation Term to Date related to this payment: $
NOTE: ALL REQUIREMENTS MUST BE MET FOR PAYMENTS
Yes
No
Comments/Deficiency
Is the Applicable signed and in effect?
Does the check request packet include appropriate supporting
documentation for the payment amount?
Does the payment amount agree to that outlined in the contract?
Does the amount and purpose of this payment appear reasonable?
Are there any contractual reconciliations or rate adjustments that need
to be made with the payment?
If the above is complete and compliant: Certify with your signature below and forward this form to Administration for review and approval of
payment. If above is not complete or incorrect; return to the Contract/Responsible Manager for follow-up / correction.
Supporting Documentation must be attached, (i.e.) physician schedules signed by physician, RVU calculation, department schedules, etc.
I certify that I have reviewed all of the above information relative to this payment request including the Monthly Activity Statements and
supporting documentation. All of the information provided is accurate and consistent with the terms of the signed Physician Employment /
Services Agreement.
_____________________________________________________
Date:_______________________
Responsible Manager Signature:
_____________________________________________________
Date:_______________________
Approved by Signature
_____________________________________________________
Date:_______________________
Requested by:
_____________________________________________________
Date:_______________________
Compliance Officer Signature
NOTE: THIS FORM MUST BE SIGNED BY THE RESPONSIBLE MANAGER / DEPARTMENT DIRECTOR AND INCLUDED IN THE
CHECK REQUEST PACKET TO BE FORWARDED TO ADMINISTRATION FOR PROCESSING.

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