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Send to pay@empowerhealthservices.com
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TIME AND EXPENSE REPORT
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First and Last NamePhone #Begin Date5/3/26MILEAGE RATE$0.67/mile
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emailStateEnd Date5/9/26MEAL RATE$40.00 per day
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HOURLY RATEMEAL RATE
$20.00 - 1/2 day
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* Reimbursed UP TO amount
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HOURS PER WEEK - Sunday through Saturday
If you have listed MISC hours, include the Reason in the Description
see Travel Policy
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DATEDESCRIPTION OF HOURSSITE CODECLIENT NAMECLIENT CITYCLIENT STATEEVENT HOURSTRAVEL HOURSMISC. HOURSTOTAL HOURS
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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 Totals0.000.000.000.00
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Partial hours, round to the nearest 15 minutes, record as: 15 minutes = .25; 30 minutes = .50 ; 45 minutes = .75
Total $ Amount$0.00
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REIMBURSABLE EXPENSES
Total Round Trip Miles
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DATEEXPENSE DESCRIPTIONSITE CODEHOTELMEALSRENTAL CAR RENTAL FUELTOLLS / PARKINGMISC.TOTAL MILESMiles Multiplied by $0.67Total Expenses
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$0.00 $0.00
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$0.00 $0.00
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$0.00 $0.00
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$0.00 $0.00
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$0.00 $0.00
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$0.00 $0.00
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$0.00 $0.00
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$0.00 $0.00
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 Totals$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
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Provider SignatureDateAdvances$0.00
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To ensure you are paid on time - submit this report to pay@empowerhealthservices.com.
Total Travel$0.00
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Submitting your TE Report to any other email may delay payment! Or send via Fax #: 630-882-0448.
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