ABCDEFGHIJKLMNOPQRSTUVWXYZ
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**PLEASE ENTER DATA IN GREEN CELLS ONLY**
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**DUE THE 1ST OF THE FOLLOWING MONTH**
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PREMIER SPECIALTY NETWORK TIMECARD
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Provider Name
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Services Provided
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Month of Service
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DayHospital / ClinicClinic HoursProcedure HoursDaily Miles Traveled (roundtrip)2023 Mileage Rate Travel Reimbursement
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1st$0.655 $0.00
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2nd$0.655 $0.00
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3rd$0.655 $0.00
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4th$0.655 $0.00
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5th$0.655 $0.00
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6th$0.655 $0.00
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7th$0.655 $0.00
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8th$0.655 $0.00
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9th$0.655 $0.00
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10th$0.655 $0.00
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11th$0.655 $0.00
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12th$0.655 $0.00
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13th$0.655 $0.00
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14th$0.655 $0.00
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15th$0.655 $0.00
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16th$0.655 $0.00
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17th$0.655 $0.00
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18th$0.655 $0.00
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19th$0.655 $0.00
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20th$0.655 $0.00
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21st$0.655 $0.00
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22nd$0.655 $0.00
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23rd$0.655 $0.00
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24th$0.655 $0.00
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25th$0.655 $0.00
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26th$0.655 $0.00
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27th$0.655 $0.00
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28th$0.655 $0.00
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29th$0.655 $0.00
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30th$0.655 $0.00
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31st$0.655 $0.00
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TOTALS000$0.00
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NOTES:
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