ClearCare Session Adjustment
Cancellations, Missed Clock-in/Clock-out or Adjustment, Mileage add on or adjustment. Please fill out the applicable sections.
PLEASE NOTE THAT PROVIDING ANY FALSE INFORMATION ON THIS FORM IS CONSIDERED FRAUD AND MAY BE PUNISHABLE BY STATE AND FEDERAL LAW. BY CONTINUING TO FILL OUT THIS FORM YOU AGREE THAT THIS INFORMATION IS CORRECT TO THE BEST OF YOUR KNOWLEDGE AND YOU PHYSICALLY WERE AT THIS LOCATION AND PROVIDED THESE SERVICES. FUNDS FOR THIS RESPITE PROGRAM ARE REIMBURSED BY THE STATE OF CALIFORNIA AND THE FEDERAL MEDICAID PROGRAM.
Respite Worker's First and Last Name:
Client(s) First and Last name:
Parent's Name (Optional):
Never submit passwords through Google Forms.
This form was created inside of Autism, Respite, Camp, & Childcare Center, LLC.