Stavros fi 2026

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The document is a payroll form for Personal Care Attendants (PCAs) under the MassHealth program, detailing the hours worked by PCAs for consumers receiving senior care services. It includes sections for recording time in and out, total hours worked, and signatures from both the employer and PCA to certify the accuracy of the reported services.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the payroll period dates at the top of the form, specifying the start and end dates.
Fill in the employer number and name, along with their contact information including home and work phone numbers.
In the time tracking section, record the hours worked each day for both Week 1 and Week 2. Use AM/PM indicators to specify times accurately.
Ensure you total the day/evening hours and night hours for each week at the bottom of their respective sections.
Finally, sign and date the form at the bottom to certify that services were provided as described.

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