Name: Date: Service: Dept: MA-billable services Time Units Total County-billable services Time Units OVR-billable services Time Units Total Non-billable services Time Units Total Grand Total Individual’s Signature: Date: Name: Staff Signature: Date:
MA-billable services Time Units Total Name: Date: Service: Dept: County-billable services Time Units OVR-billable services Time Units Total Non-billable services Time Units Total Individual’s Signature: Date: Grand Total Name: Staff Signature: Date:
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