Enter the amount of wages paid to the Individual. It is possible that the wage amount may change between WAGES DOLLAR AMOUNT TEXT the time of placement and final check. Enter the current wage amount at the time of the specific report. Enter the schedule or frequency of the Individual’s pay check. Hourly Weekly WAGES FREQUENCY DROP DOWN Bi-Weekly Monthly Quarterly Annually Enter the date that the Individual received their first DATE OF FIRST PAYCHECK DATE pay check. if the Employer makes Medical Check “YES” Insurance available, regardless of whether the EMPLOYER PROVIDED MEDICAL INSURANCE CHECK BOX Individual opts to accept the insurance or not. If no Employer provided health insurance is available, AVAILABLE? check “NO.” Enter the date of the final contact for the purpose of employment verification. Date must occur between DATE OF FINAL EMPLOYMENT DATE day 83 and day 90 of successful employment. Start VERIFICATION date of successful employment shall be determined by VR Staff or VR Contractor. Enter the source of the medical insurance Individual’s at the time of the final employment verification. None Information Not Available Not Yet Eligible For Employer Medical SOURCE OF MEDICAL INSURANCE AT TIME OF FINAL DROP DOWN Employer Medical Insurance EMPLOYMENT VERIFICATION Medicaid Medicare State/Federal Affordable Care Act Other Public Insurance Other Private Insurance Enter any information that was provided by the COMMENTS TEXT Individual that may be important for VR Staff or VR Contractor to be aware of. Signatures must be original signatures, e.g. “wet ink” or image captured through a signature pad. Signatures SIGNATURES FILL IN may not be stored for future use.
WAGES DOLLAR AMOUNT TEXT Enter the amount of wages paid to the Individual. It is possible that the wage amount may change between the time of placement and final check. Enter the current wage amount at the time of the specific report. WAGES FREQUENCY DROP DOWN Enter the schedule or frequency of the Individual’s pay check. Hourly Weekly Bi-Weekly Monthly Quarterly Annually DATE OF FIRST PAYCHECK DATE Enter the date that the Individual received their first pay check. EMPLOYER PROVIDED MEDICAL INSURANCE AVAILABLE? CHECK BOX Check “YES” if the Employer makes Medical Insurance available, regardless of whether the Individual opts to accept the insurance or not. If no Employer provided health insurance is available, check “NO.” DATE OF FINAL EMPLOYMENT VERIFICATION DATE Enter the date of the final contact for the purpose of employment verification. Date must occur between day 83 and day 90 of successful employment. Start date of successful employment shall be determined by VR Staff or VR Contractor. SOURCE OF MEDICAL INSURANCE AT TIME OF FINAL EMPLOYMENT VERIFICATION DROP DOWN Enter the source of the Individual’s medical insurance at the time of the final employment verification. None Information Not Available Not Yet Eligible For Employer Medical Employer Medical Insurance Medicaid Medicare State/Federal Affordable Care Act Other Public Insurance Other Private Insurance COMMENTS TEXT Enter any information that was provided by the Individual that may be important for VR Staff or VR Contractor to be aware of. SIGNATURES FILL IN Signatures must be original signatures, e.g. “wet ink” or image captured through a signature pad. Signatures may not be stored for future use.
VR%20Provider%20Manual%20-%20Effective%20010118.docx