Form 02AD005E "Aces$ Oklahoma Employee Pay Rate Sheet" - Oklahoma

What Is Form 02AD005E?

This is a legal form that was released by the Oklahoma Department of Human Services - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Oklahoma Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 02AD005E by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Human Services.

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Download Form 02AD005E "Aces$ Oklahoma Employee Pay Rate Sheet" - Oklahoma

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ACES$ Oklahoma Employee Pay Rate Sheet
Member/Employer name
ACES$ member ID
Employee name
Employee Social Security number
Service plan begin date:
Note: Pay rate modifications can only be made at the time of your annual reassessment. The
employer must advise employee of any rate changes.
Rate Information Worksheet
Employer: Indicate what services your employee will and will not provide. Make sure not to go
below the minimum wage rate or above the maximum rate established at your interdisciplinary team
meeting.
Will employee provide
Minimum
Unit/
Service name
Wage rate
service?
wage rate
per
Yes
No
Personal Services Assistant (PSA)
$7.25
hour
Yes
No
Advanced personal services assistant (APSA)
$7.25
hour
Employer signature
Employer name
Date
Routing
Send to:
ACES$ Financial Management Services
5801 East 41st Street, Suite 601
Tulsa, OK 74135
Fax: 1 (877) 550-6424
To securely email your form, please email a request to:
SecureOK@mycil.org
02AD005E
1/1/2019
Page 1 of 1
ACES$ Oklahoma Employee Pay Rate Sheet
Member/Employer name
ACES$ member ID
Employee name
Employee Social Security number
Service plan begin date:
Note: Pay rate modifications can only be made at the time of your annual reassessment. The
employer must advise employee of any rate changes.
Rate Information Worksheet
Employer: Indicate what services your employee will and will not provide. Make sure not to go
below the minimum wage rate or above the maximum rate established at your interdisciplinary team
meeting.
Will employee provide
Minimum
Unit/
Service name
Wage rate
service?
wage rate
per
Yes
No
Personal Services Assistant (PSA)
$7.25
hour
Yes
No
Advanced personal services assistant (APSA)
$7.25
hour
Employer signature
Employer name
Date
Routing
Send to:
ACES$ Financial Management Services
5801 East 41st Street, Suite 601
Tulsa, OK 74135
Fax: 1 (877) 550-6424
To securely email your form, please email a request to:
SecureOK@mycil.org
02AD005E
1/1/2019
Page 1 of 1