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GT Independence 5150 N Port Washington Rd, Suite 102, Milwaukee,
WI 53217Toll Free 1.877.659.4500 Fax 1.877.600.4129
www.gtindependence.com
IRIS Participant Hired Worker FEA Welcome Paperwork
Checklist
Documents provided to Worker upon issue of Start Date.Summary
Fair Credit Reporting Act Rights – two pagesGT Independence
Preferred Payment Method Form – three pagesGT Independence
Caregiver Link Application – optionalGT Independence IRIS
Timesheet
GT Independence IRIS Timesheet Submission Guidelines
GT Independence IRIS Email Timesheet Submission
GT Independence Timesheet Notification Registration – optionalGT
Independence Your Caregiver Portal Account
GT Independence 2016 Service Provider Payroll Schedule IRIS P –
two pages
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Para informacion en espanol, visite
www.consumerfinance.gov/learnmore o escribe a la Consumer Financial
Protection Bureau, 1700 G Street N.W., Washington, DC 20006.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the
accuracy, fairness, and privacy of information in the files of
consumer reporting agencies. There are many types of consumer
reporting agencies, including credit bureaus and specialty agencies
(such as agencies that sell information about check writing
histories, medical records, and rental history records). Here is a
summary of your major rights under the FCRA. For more information,
including information about additional rights, go to
www.consumerfinance.gov/learnmore or write to: Consumer Financial
Protection Bureau, 1700 G Street N.W., Washington, DC 20006.
• You must be told if information in your file has been used
against you. Anyone who uses a credit report or another type of
consumer report to deny your application for credit, insurance, or
employment - or to take another adverse action against you - must
tell you, and must give you the name, address, and phone number of
the agency that provided the information.
• You have the right to know what is in your file. You may
request and obtain all the information about you in the files of a
consumer reporting agency (your "file disclosure"). You will be
required to provide proper identification, which may include your
Social Security number. In many cases, the disclosure will be free.
You are entitled to a free file disclosure if:
• a person has taken adverse action against you because of
information in your credit report; • you are the victim of identify
theft and place a fraud alert in your file; • your file contains
inaccurate information as a result of fraud; • you are on public
assistance; • you are unemployed but expect to apply for employment
within 60 days.
In addition, all consumers are entitled to one free disclosure
every 12 months upon request from each nationwide credit bureau and
from nationwide specialty consumer reporting agencies. See
www.consumerfinance.gov/learnmore for additional information.
• You have the right to ask for a credit score. Credit scores
are numerical summaries of your credit-worthiness based on
information from credit bureaus. You may request a credit score
from consumer reporting agencies that create scores or distribute
scores used in residential real property loans, but you will have
to pay for it. In some mortgage transactions, you will receive
credit score information for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate
information. If you identify information in your file that is
incomplete or inaccurate, and report it to the consumer reporting
agency, the agency must investigate unless your dispute is
frivolous. See www.consumerfinance.gov/learnmore for an explanation
of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate,
incomplete, or unverifiable information. Inaccurate, incomplete or
unverifiable information must be removed or corrected, usually
within 30 days. However, a consumer reporting agency may continue
to report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative
information. In most cases, a consumer reporting agency may not
report negative information that is more than seven years old, or
bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting agency
may provide information about you only to people with a valid need
- usually to consider an application with a creditor, insurer,
employer, landlord, or other business. The FCRA specifies those
with a valid need for access.
• You must give your consent for reports to be provided to
employers. A consumer reporting agency may not give out information
about you to your employer, or a potential employer, without your
written consent given to the employer. Written consent generally is
not required in the trucking industry. For more information, go to
www.consumerfinance.gov/learnmore.
• You may limit "prescreened" offers of credit and insurance you
get based on information in your credit report.Unsolicited
"prescreened" offers for credit and insurance must include a
toll-free phone number you can call if you choose to remove your
name and address from the lists these offers are based on. You may
opt-out with the nationwide credit bureaus at 1-888-567-8688.
• You may seek damages from violators. If a consumer reporting
agency, or, in some cases, a user of consumer reports or a
furnisher of information to a consumer reporting agency violates
the FCRA, you may be able to sue in state or federal court.
• Identity theft victims and active duty military personnel have
additional rights. For more information,
www.consumerfinance.gov/learnmore.
Page 2 of 4
11/25/2012
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States may enforce the FCRA, and many states have their own
consumer reporting laws. In some cases, you may have more rights
under state law. For more information, contact your state or local
consumer protection agency or your state Attorney General. For
information about your federal rights, contact:
TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit unions with total
assets of over $10 billion and their affiliates.
b. Such affiliates that are not banks, savings associations, or
credit unions also should list, in addition to the Bureau:
a. Bureau of Consumer Financial Protection1700 G Street
NWWashington, DC 20006
b. Federal Trade Commission: Consumer Response Center -
FCRAWashington, DC 20580(877) 382-4357
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal
branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks
(other than federal branches, federal agencies, and insured state
branches of foreign banks), commercial lending companies owned or
controlled by foreign banks, and organizations operating under
section 25 or 25A of the Federal Reserve Act
c. Nonmember Insured Banks, Insured State Branches of Foreign
Banks, and insured state savings associations
d. Federal Credit Unions
a. Office of the Comptroller of the CurrencyCustomer Assistance
Group1301 McKinney Street, Suite 3450Houston, TX 77010-9050
b. Federal Reserve Consumer Help CenterP.O. Box 1200Minneapolis,
MN 55480
c. FDIC Consumer Response Center1100 Walnut Street, Box
#11Kansas City, MO 64106
d. National Credit Union AdministrationOffice of Consumer
Protection (OCP)Division of Consumer Compliance and Outreach
(DCCO)1775 Duke StreetAlexandria, VA 22314
3. Air carriers Asst. General Counsel for Aviation Enforcement
& ProceedingsDepartment of Transportation400 Seventh Street
SWWashington, DC 20590
4. Creditors Subject to Surface Transportation Board Office of
Proceedings, Surface Transportation BoardDepartment of
Transportation1925 K Street NWWashington, DC 20423
5. Creditors Subject to Packers and Stockyards Act Nearest
Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy
Administrator for Capital AccessUnited States Small Business
Administration406 Third Street, SW, 8th FloorWashington, DC
20416
7. Brokers and Dealers Securities and Exchange Commission100 F
St NEWashington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal
Intermediate Credit Banks, and Production Credit Associations
Farm Credit Administration1501 Farm Credit DriveMcLean, VA
22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not
Listed Above FTC Regional Office for region in which the creditor
operates orFederal Trade Commission: Consumer Response Center -
FCRAWashington, DC 20580(877) 382-4357
Page 3 of 4
11/25/2012
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GT IndependencePreferred Payment Method Form
Employee Information Employee Name:
Paycard Paycard Information:
By providing the information requested above and signing below,
I hereby elect and consent to receive my wages,including but not
limited to off cycle wage payments and wage payments upon
discharge, by electronic transfer ofwages to a paycard. In
addition, to the extent permitted by applicable law, I hereby
authorize GT Independence tomake all of my deposits and deposit
adjustments, including those involving off cycle wage payments and
wagepayments upon discharge, to my paycard, and I authorize the
bank where such funds are deposited to accept suchdeposits and make
such adjustments. I acknowledge I have received a copy of the
terms, conditions, and feesassociated with using such paycard. This
authorization shall remain in effect until fourteen (14) days after
GTIndependence receives written notice from me terminating my
authorization.
Direct Deposit Bank Account Information:
Bank Name: Deposit Amount: $
Additional Information for Direct Deposit: Typically pay should
be automatically deposited into your account(s) within 2 pay
periods. It is your responsibility to notify Payroll of any changes
to/closure of your bank account. Failure to notify
Payroll may delay issuance of checks. You must provide a voided
check drawn from the account (no deposit slips) or a letter from
the bank on
official letterhead to verify the ABA and account #. Incomplete
or inaccurate information will not beprocessed.
Green Initiative: You are automatically enrolled in our Green
Initiative Program.Electronic Paystubs. By signing below, I hereby
elect and consent to receive my paystubs electronically over the
Internet. In
Electronic W-2s. By signing below, I hereby elect and consent to
receive my W-2s electronically over the Internet. At anypoint in
time I decide to receive a paper copy of my W-2 form instead, I
will notify GT independence in writing of such request.
Green Initiative Opt Out: By checking here and signing below, I
hereby state that I am opting out of the Green Initiativeprogram
offered by GT independence. I prefer to receive paper copies of
paystubs and W-2s.
Employee Name (Print Name): Date:
Employee Signature Authorizing Payment Method:
INTERNAL USE ONLYDATATRAC File
Paycard Number:
Account Type: Checking SavingsABA/Routing #: Account #:
Employer:
Street Address 1: City: State: Zip:
Date Of Birth: Social Security Number:
addition, I may access the electronic paystubs by phone, email,
fax, abbreviated text message, or by calling Customer
Servicedirectly at 1-877-659-4500.
akujacznskiRectangle
akujacznskiTypewritten text*for office use only
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Introducing the Global Cash Card Paycard- a great alternative to
physical paychecks and eventraditional bank accounts. The Global
Cash Card is a great place to start for your electronicpayment
options.
The World’s Largest Surcharge-Free ATM Network. Over60,000
surcharge-free ATM locations worldwide.
Shop● Retail stores, convenience stores, gas stations,
grocerystores, restaurants, Internet. On-line or in stores, useyour
paycard for purchases anywhere VISA is accepted.
● Use your paycard as a Credit (signature) transaction andthere
is No Fee!
Get Cash● Over 60,000 surcharge-free ATM locations Worldwide.Go
to www.allpointnetwork.com to find the closest ATM toyou.
● Use your pin to get “cash back” at many point of
salelocations.
Family Cards● Receive up to five additional paycards for
familymembers (students, military personnel, family out of
thecountry) at No Fee.
● No Fee for card to card transfers. Cardholder only hasaccess
to money transferred to their paycard.
Safe to use
Convenient
Everyone Qualifies!
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How it works:1. Your wages will be deposited onto the Global
CashCard Visa paycard each pay period for immediate use.
2. Set up paycard alerts and two-way texting: Receive email and
text message alerts when your
paycard is loaded on payday Receive low balance alert when
paycard balance
falls below a predetermined amount Text and receive your paycard
balance, activity,
and payroll loads within seconds
3. Access your money in many ways: Make signature purchases with
No Fee at any
merchant that accepts a Visa paycard Withdraw funds at Allpoint
Network surcharge-
free ATM locations Receive cash back after making a debit
purchase
at many locations
3. Benefits Cashless transactions protect your money from
theft No more check cashing fees, purchasing money
orders or waiting on your paycheck Better money management and
more accurate
budgeting when you track your transactions fromyour smart phone,
on-line, or on the phone
“No Hidden Fees” Detail
PAYCARD PROGRAMENROLLMENT FEE/ANNUAL FEE/MONTHLY FEE NO
FEEREWARDS PROGRAM ENROLLMENT NO FEECARD REPLACEMENT NO
FEEINACTIVITY FEE / MONTHLY $3.00
(AFTER NINETY (90) DAYS OF NO TRANSACTIONS – LOADS
ARETRANSACTIONS)
PIN CHANGE NO FEEAUTOMATED/OPERATOR ASSISTED TELEPHONE NO FEEWEB
SITE LOGIN NO FEE
FIRST TRANSACTION PER PAY PERIOD NO FEE
ATM – UNITED STATESWITHDRAWAL (SURCHARGE FREE/ALLPOINT)
$1.75WITHDRAWAL (OUT OF NETWORK) $1.75OTHER TRANSACTIONS $1.00
ATM – OUTSIDE UNITED STATESWITHDRAWAL $3.50*OTHER TRANSACTIONS
$3.25
POINT OF SALE – UNITED STATESSIGNATURE PURCHASE NO FEEPIN
PURCHASE NO FEEDECLINE – SIGNATURE/PIN $0.80/$0.45
POINT OF SALE – OUTSIDE UNITED STATESSIGNATURE PURCHASE NO
FEE*PIN PURCHASE $1.75DECLINE - SIGNATURE/PIN $1.50/$1.25
BALANCE INQUIRYONLINE/IVR/LIVE CUSTOMER SERVICE NO FEE
MONEY TRANSFER WORLDWIDE (CARD TO CARD)$1 - $2500 (DAILY LIMIT
IS $2,500) NO FEE
BILL PAYCARDHOLDER DIRECT TO MERCHANT NO FEEONLINE
$0.99TELEPHONE/CONVENIENCE CHECK $1.50
*CURRENCY CONVERSION FEE MAY APPLYHow to get it:Contact GT
Independence Today at:
1-877-659-4500
Questions regarding your new Global CashCard Visa paycard
contact us at:
949-751-0360 or visit us on-line atwww.globalcashcard.com
The Global Cash Card Visa Prepaid Card is issued by First
California Bank and MetaBankTM, member FDIC,pursuant to a license
from VISA U.S.A. Inc.
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GT IndependenceCaregiver Link Application
Dear Caregiver:
Do you have an interest in additional work hours? GT
independence has a resource tool calledCaregiver Link, which is an
online caregiver directory. The directory works to
connectindividuals seeking provider services and supports with
potential people who enjoy working inthe care giving field.
Please complete the information below and return this form to GT
by fax at 888.972.3891 to beadded to our caregiver directory. Your
completion of this form does not guaranteeemployment, however it
may provide you with an opportunity to provide
Self-Directedsupports for one or more additional people. GT
Independence encourages you to meet andinterview with any
opportunities that you may receive to provide supports for
additionalpeople.
Application – Please printNAME:ADDRESS: (Street address, city,
state, zip code)
PHONE NUMBER(S):
EMAIL ADDRESS:
Are you at least 18 years old? Medicaid funding requires you to
be a minimum of 18 years old.Circle one: YES / NO
Do you have your own transportation? Circle one: YES / NO
Do you have experience working with people who have a
disability? Circle one: YES / NO
When are you able to work? Circle all that apply:DAYS / NIGHTS /
WEEKENDS
Please note the days you are unavailable to work.
Have you ever been convicted of a felony or misdemeanor? Circle
one: YES / NO
By signing this application you are consenting to GT
Independence sharing your name andphone number with potential
individuals needing services/supports, and Care Managers
withManaged Care Organizations.
Employee Signature Date
INTERNAL USE ONLYDATATRAC File
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Period Begins:
Period Ends:
Self Determination Timesheet
MM/DD/YY
MM/DD/YY
Participant:
Participant-Hired Worker:
Date:____/____/___ MM/DD/YY
Participant-Hired Worker
Signature:__________________________________
Date:____/____/___ MM/DD/YY
Participant/Supervisor
Signature:__________________________________
The Participant Employer/Guardian and Participant HiredWorker
certify that the information provided on this time
report is a true and accurate statement of the servicesprovided.
The Participant Employer/Guardian and
Participant Hired Worker understand that payment forservices
provided are the subject to payroll taxes.
SUBMIT TIMESHEETSFAX: 855-329-8648Email:
[email protected]: GT Independence215 Broadus St.
Sturgis, MI 49091
Please call GT Independence at877-659-4500 with any questions
on
how to complete this form
Day ofWeek
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Total Hours - Week 1
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Day ofWeek
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Service Code Service Code Service Code Service Code
Total Hours - Week 2
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GT Independence Customer Service877-659-4500
Timesheet Submission:Fax: 855-FAX-TO-GT or 855-329-8648E-mail:
[email protected]: 215 Broadus St.
Sturgis, MI 49091
IRIS Timesheet Submission Guidelines
Did you send your timesheet in on time?You do not have to wait
for the due date to send in your timesheets. Our fax machines and
e-mail system can accept faxes 24 hours/ day, 7days/week. Refer to
the payroll schedule to assure you are submitting your timesheet on
time. Timesheets cannot be submitted before all of thehours are
worked. Late timesheets will be paid on the following pay period.
Please contact Customer Service with any questions,
1-877-659-4500.
Are your timesheets legible?Take your time in completing your
timesheet. Please print clearly in blue or black ink.
Have you filled in the pay period dates at the top of your
timesheet?Please refer to the payroll schedule you have been
provided for the correct payroll period.
Have you included all of the time worked for this payroll
period?
Did you work all of the hours you submitted?It is fraudulent to
report hours you did not work. You cannot report hours while the
member you are providing services for is hospitalized or in
amedical facility (i.e. hospital, nursing home, rehab).
Did you report your time in the correct format and include AM
and PM?You need to report time in fifteen minute increments. For
example, 8:06 AM – 10:35 AM should be reported as 8:15 AM – 10:30
AM. Each fifteenminute increment is equal to one quarter of an
hour. .25 hours = 15 minutes, .50 hours = 30 minutes, .75 hours =
45 minutes
Does your time in and time out equal the hours reported for each
day?
Did you include the correct service code for each day worked?The
employee folder provided to you includes the correct service code
information. If you are unsure about which service code you should
beusing please contact Customer Service at 877-659-4500.
Did you total your hours at the bottom of your timesheet for the
current pay period?
Did you make sure not to use white out on your timesheet?If you
make an error on your timesheet you should correct it by drawing a
single line through it. Both the employer and employee should date
andinitial the correction.
Did you fully complete each section of the timesheet?You may not
draw lines, arrows, or use ditto marks to complete sections of your
timesheet. Each section must be completed even if theinformation is
the same.
Did the employee and employer both sign and date the timesheet
with month, date, and year on or after the lastdate worked?Be sure
that your timesheet is signed by the Employer and the Employee
along with the date. The date must be the complete date with
month,date, and year and be on or after the last date worked.
If you needed to resubmit a timesheet did you write “REFAX” at
the top of the timesheet?
Did you report more hours than authorized?Your timesheet may be
delayed if you report more hours than you were approved to
provide.
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GT Independence215 Broadus Sturgis, MI 49091
877.659.4500 www.gtindependence.com
Your life. Your choice.
IRIS EMAIL TIMESHEET SUBMISSION
In an effort to make the payroll process smoother and easier for
you, GT Independence has developed asystem for submitting your
timesheets via email. This process allows you to submit your
timesheet to usand can also send you a notification letting you
know that your timesheet has been received.Use the instructions
below to begin submitting your timesheet via email. You will
automatically receive areply within minutes of sending your email
confirming that we received your email and attachment ornotifying
you if your attachment needs to be resent.
Using Email Timesheet Submissions:
1. Attach your timesheet to an email - PDF is the best format to
use to ensure successful receipt ofyour timesheet.
2. Use Subject Line “Timesheet Attached” – The subject line of
the email MUST include“Timesheet Attached” in order for us to send
you email notifications.
3. Send Email To [email protected]. Receive Confirmation
– Once we receive your email and check for attachments we will
immediately send you a confirmation letting you know that it has
been received and confirmingthat your attachment came through.
Using Your Phone to Submit Your Timesheet:
NOTICE iPhone/Android USERS: If you are using your smartphone to
send in your timesheet there areseveral free apps like Genius Scan
or TinyScan that allow you to email your timesheet in PDF format
toensure that it can be read. The following instructions are for
using the Genius Scan App. PLEASE NOTE:This is not an endorsement
of any app or mobile platform. Download apps at your own risk.
Standarddata rates may apply.
1. Download the Genius Scan App from the App Store or Android
Marketplace2. Open App on your device3. Click on the camera icon in
the app and take a picture of your entire Timesheet4. Click the
export function in the bottom right corner of the screen5. Select
PDF Format6. Select export to EMAIL7. Use Subject Line “Timesheet
Attached” – The subject line of the email MUST include
“Timesheet Attached” in order for us to send you email
notifications.8. Send Email To [email protected]
GT Independence215 Broadus Sturgis, MI 49091
877.659.4500 www.gtindependence.com
Your life. Your choice.
IRIS EMAIL TIMESHEET SUBMISSION
In an effort to make the payroll process smoother and easier for
you, GT Independence has developed asystem for submitting your
timesheets via email. This process allows you to submit your
timesheet to usand can also send you a notification letting you
know that your timesheet has been received.Use the instructions
below to begin submitting your timesheet via email. You will
automatically receive areply within minutes of sending your email
confirming that we received your email and attachment ornotifying
you if your attachment needs to be resent.
Using Email Timesheet Submissions:
1. Attach your timesheet to an email - PDF is the best format to
use to ensure successful receipt ofyour timesheet.
2. Use Subject Line “Timesheet Attached” – The subject line of
the email MUST include“Timesheet Attached” in order for us to send
you email notifications.
3. Send Email To [email protected]. Receive Confirmation
– Once we receive your email and check for attachments we will
immediately send you a confirmation letting you know that it has
been received and confirmingthat your attachment came through.
Using Your Phone to Submit Your Timesheet:
NOTICE iPhone/Android USERS: If you are using your smartphone to
send in your timesheet there areseveral free apps like Genius Scan
or TinyScan that allow you to email your timesheet in PDF format
toensure that it can be read. The following instructions are for
using the Genius Scan App. PLEASE NOTE:This is not an endorsement
of any app or mobile platform. Download apps at your own risk.
Standarddata rates may apply.
1. Download the Genius Scan App from the App Store or Android
Marketplace2. Open App on your device3. Click on the camera icon in
the app and take a picture of your entire Timesheet4. Click the
export function in the bottom right corner of the screen5. Select
PDF Format6. Select export to EMAIL7. Use Subject Line “Timesheet
Attached” – The subject line of the email MUST include
“Timesheet Attached” in order for us to send you email
notifications.8. Send Email To [email protected]
GT Independence215 Broadus Sturgis, MI 49091
877.659.4500 www.gtindependence.com
Your life. Your choice.
IRIS EMAIL TIMESHEET SUBMISSION
In an effort to make the payroll process smoother and easier for
you, GT Independence has developed asystem for submitting your
timesheets via email. This process allows you to submit your
timesheet to usand can also send you a notification letting you
know that your timesheet has been received.Use the instructions
below to begin submitting your timesheet via email. You will
automatically receive areply within minutes of sending your email
confirming that we received your email and attachment ornotifying
you if your attachment needs to be resent.
Using Email Timesheet Submissions:
1. Attach your timesheet to an email - PDF is the best format to
use to ensure successful receipt ofyour timesheet.
2. Use Subject Line “Timesheet Attached” – The subject line of
the email MUST include“Timesheet Attached” in order for us to send
you email notifications.
3. Send Email To [email protected]. Receive Confirmation
– Once we receive your email and check for attachments we will
immediately send you a confirmation letting you know that it has
been received and confirmingthat your attachment came through.
Using Your Phone to Submit Your Timesheet:
NOTICE iPhone/Android USERS: If you are using your smartphone to
send in your timesheet there areseveral free apps like Genius Scan
or TinyScan that allow you to email your timesheet in PDF format
toensure that it can be read. The following instructions are for
using the Genius Scan App. PLEASE NOTE:This is not an endorsement
of any app or mobile platform. Download apps at your own risk.
Standarddata rates may apply.
1. Download the Genius Scan App from the App Store or Android
Marketplace2. Open App on your device3. Click on the camera icon in
the app and take a picture of your entire Timesheet4. Click the
export function in the bottom right corner of the screen5. Select
PDF Format6. Select export to EMAIL7. Use Subject Line “Timesheet
Attached” – The subject line of the email MUST include
“Timesheet Attached” in order for us to send you email
notifications.8. Send Email To [email protected]
-
Employee Name: Agency:
I Provide Services For (Participant Name): Method of
Notification:
E-mail OR SMS Text Message
E-mail: Cell Phone #:
Provider(Cell Phone Company):
GT Independence
Timesheet Notification Registration
GT Independence can notify you of the receipt of your timesheet
by sending an email
notification or SMS (Short Message Service) text message. To
sign up for this notification
service, please fill out the information below and submit
via:
Mail: 215 Broadus St
Sturgis, MI 49091
Fax: 888-972-3891
E-mail: [email protected]
Please print clearly
Please allow two to four weeks for processing. Once activated,
notifications will be sent within
2 business days of receipt of the timesheet. This notification
does not guarantee the timesheet
will be paid, only that it has been received. GT Independence
will contact the appropriate
parties if the timesheet cannot be processed.
By signing below, I agree to not hold GT Independence
responsible for the privacy of the
message or any text message/data rates that may be incurred.
Employee Signature Date
To cancel notifications, please submit a completed Status Change
Form, available by contacting
Customer Service at 877-659-4500.
mailto:[email protected]:[email protected]
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GT Independence Page 1 of 2 2016 Service Provider Payroll
Schedule IRIS P
Service Dates: Timesheets Due by 5:00 pm: Direct Deposit
Prepared by:
Mar.06 - Mar.19, 2016 Friday, March 25, 2016 Friday, April 08,
2016
Mar.20 – Apr.02 Friday, April 08, 2016 Friday, April 22,
2016
Apr.03 – Apr.16 Friday, April 22, 2016 Friday, May 06, 2016
Apr.17 – Apr.30 Friday, May 06, 2016 Friday, May 20, 2016
May.01 – May.14 Friday, May 20, 2016 Friday, June 03, 2016
May.15 – May.28 Friday, June 03, 2016 Friday, June 17, 2016
May.29 – Jun.11 Friday, June 17, 2016 Friday, July 01, 2016
Jun.12 – Jun.25 Friday, July 01, 2016 Friday, July 15, 2016
Jun.26 – Jul.09 Friday, July 15, 2016 Friday, July 29, 2016
Jul.10 – Jul.23 Friday, July 29, 2016 Friday, August 12,
2016
Jul.24 – Aug.06 Friday, August 12, 2016 Friday, August 26,
2016
Aug.07 – Aug.20 Friday, August 26, 2016 Friday, September 09,
2016
Aug.21 – Sep.03 Friday, September 09, 2016 Friday, September 23,
2016
Sep.04 – Sep.17 Friday, September 23, 2016 Friday, October 07,
2016
Sep.18 – Oct.01 Friday, October 07, 2016 Friday, October 21,
2016
Oct.02 – Oct.15 Friday, October 21, 2016 Friday, November 04,
2016
Oct.16 – Oct.29 Friday, November 04, 2016 Friday, November 18,
2016
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GT Independence Page 2 of 2 2016 Service Provider Payroll
Schedule IRIS P
The office will be closed on the following days:
Thursday, December 24, 2015 Friday, December 25, 2015 Friday,
January 1, 2016 Monday, May 30, 2016 Monday, July 4, 2016 Monday,
Sept. 5, 2016 Thursday, November 24, 2016 Friday, November 25, 2016
Friday, December 23, 2016 Monday, December 26, 2016 Monday, January
2, 2017
Service Dates: Timesheets Due by 5:00 pm: Direct Deposit
Prepared by:
Oct.30 – Nov12 Friday, November 18, 2016 Friday, December 02,
2016
Nov.13 – Nov.26 Friday, December 02, 2016 Friday, December 16,
2016
Nov.27 – Dec.10 Friday, December 16, 2016 Friday, December 30,
2016
Dec.11 – Dec.24 Friday, December 30, 2016 Friday, January 13,
2017
Dec.25 – Jan. 07, 2017 Friday, January 13, 2017 Friday, January
27, 2017
Jan.08 – Jan.21 Friday, January 27, 2017 Friday, February 10,
2017
***If your timesheet requires a refax or
resubmission your payment will be
delayed.
***Timesheets submitted that are over
the authorized amount may not be eligible
for payment. Please only submit time that
has been authorized.
Please remember the following about your time sheets:
Please review the Timesheet Submission Guidelines to assure your
timesheet is complete
Time sheets must be completed with blue or black ink
Time sheets are to be signed and dated by the employee and the
employer
Signature dates should be in MM/DD/YY format
Must be completed with printed employer and employee names,
dates, times and service type
Only one entry is allowed per row on the time sheet - submit
multiple time sheets if necessary
Incorrect time sheets will require resubmission of corrected
time sheets and will delay payment
All resubmissions are required to have “REFAX” written at the
top of the time sheet
When working for multiple employers, you must turn in a time
sheet for each employer
Late time sheets will be held until the following pay period
White-out, ditto marks or lines drawn down the columns are not
permitted
Time sheets are accepted by e-mail and fax 24 hours per day, 7
days per week
Fax your timesheets to 855-FAX-TO-GT (855-329-8648)
Time sheets are accepted by email at
[email protected] with employer consent
For assistance please do not hesitate to call Customer Service
at 877-659-4500
Please note the pay date listed is the date your payroll is
prepared. Direct deposits will be sent to your bank or
financial
institution on this date, but are not guaranteed to post to your
account. GT Independence does not control your bank or
financial institution's process for posting direct deposits.
Check your bank account the following day for a direct deposit
posting.
Changed- IRIS Participant Hired Worker Packet.pdf
(p.1-33)Relationship Disclosure.pdf (p.29)
2016 Service Provider Payroll Schedule IRIS P.pdf (p.34-35)
BUDSTART: Text1: 1Text2: 2EMPFIRST: EMPLAST: EMPMID: EMPDOB:
EMPSTREET: EMPCITY: EMPSTATE: EMPZIP: RESIDENCY YRS 1: PREV:
ADDRESS 2: ADDRESS 3: EMPSTREET_1: EMPCITY_1: EMPSTATE_1: EMPZIP_1:
EMPCOUNTY_1: EMPSTREET_2: EMPCITY_2: EMPSTATE_2: EMPZIP_2:
EMPCOUNTY_2: EMPSTREET_3: EMPCITY_3: EMPSTATE_3: EMPZIP_3:
EMPCOUNTY_3:
RESIDENCY YRS 2: MAIDEN/PREVIOUS NAMES_2: RESIDENCY YRS 3:
MAIDEN/PREVIOUS NAMES_3: 1: 2: 3: 4: 5: MOTHER'S MAIDEN NAME:
MOTHER'S CURRENT NAME: FATHER'S CURRENT NAME: TITLE_PROVIDER:
EmployeeMAIDEN/PREVIOUS NAMES_1: EMPGENDER: EMPSSN: MEMFIRST:
MEMLAST: MEMADD: MEMCITY: MEMSTATE: MEMZIP: CheckBox26:
OffCheckBox27: OffCheckBox28: OffCheckBox30: OffCheckBox29:
OffCheckBox32: OffCheckBox31: OffCheckBox33: OffCheckBox34:
OffCheckBox36: OffCheckBox35: OffSignatureDate: Signature: Text8:
CheckBox19: OffDIVORCE DATE: CheckBox1: OffCheckBox2: OffPROVIDER
SIGN: PROVIDER DATE: EMPLOYER SIGN: EMPLOYER DATE: EMPHOME:
CheckBox46: OffText4: EMPEMAIL: MEMMID: MEMDOB: MCI: MEMHOME:
MEMEMAIL: SIGN: DATE: tasks and duties:: Participant requires
assist with Instrumental Activities of Daily Living/ Activities of
Daily Living (IADs/ADLs) as identified in Long Term Care -
Functional Screen (LTC-FC) and/or Individual Supports and Services
(ISSP).Provide for training:: Participant agrees to provide needed
training to allow Participant Hired Worker to perform cares for
Participant per Participant requirements.CheckBox47: OffCheckBox48:
OffCheckBox49: OffCheckBox50: OffCheckBox51: OffCheckBox52:
OffCheckBox53: OffCheckBox54: OffCheckBox55: OffCheckBox56:
OffCheckBox57: OffCheckBox58: OffCheckBox59: OffCheckBox60:
OffCheckBox61: OffCheckBox62: OffCheckBox63: OffCheckBox64:
OffCheckBox65: OffCheckBox66: OffCheckBox67: OffCheckBox68:
OffCheckBox69: OffCheckBox70: OffCheckBox71: OffCheckBox72:
OffCheckBox73: OffCheckBox74: OffCheckBox75: OffCheckBox76:
OffCheckBox77: OffCheckBox78: OffCheckBox79: OffCheckBox80:
OffCheckBox81: OffPayrate 1: Payrate 2: Payrate 3: Payrate 4:
Mileage1: Unit Type 1: Unit Type 2: Unit Type 3: Unit Type 4:
Mileage2: Units/Week1: Units/Week2: Units/Week3: Units/Week4:
Mileage3: Text3: BLANK: DateofHire: CheckBox3: OffCheckBox4:
OffCheckBox5: OffCheckBox6: OffCheckBox7: OffCheckBox8:
OffCheckBox9: OffTRAINING COMPLETED 1: CheckBox10: OffCheckBox11:
OffCheckBox12: OffCheckBox13: OffCheckBox14: OffCheckBox15:
OffCheckBox16: OffCheckBox17: OffTRAINING COMPLETED 2: CheckBox18:
OffCheckBox20: OffCheckBox21: OffCheckBox22: OffCheckBox23:
OffCheckBox24: OffCheckBox25: OffTRAINING COMPLETED 3: A: B: C: D:
E: F: G: EMPAPT: H: LINE6: LINE7: Text221: CheckBox43:
OffCheckBox44: OffCheckBox45: OffLINES A - C: LINES A - D: MEMEIN:
FSRFIRST: FSRLAST: Text6: Last Name Family Name First Name Given
Name Middle Initial Other Names Used if any: Check Box1:
OffText29362: trans date: Address Street Number and Name_2: 215
Broadus St.City or Town State: Sturgisstate trans: MIZip Code:
49091Text25: Text26: Text27: Text28: Text34: Text36: Text37:
Text38: Signature of Employer or Authorized Representative I Date
mmddyyyy I Title of Employer or Authorized Representative:
EMPLOYER_TITLE: EmployerBANKNAME: blank: Notes: Signature Date:
ICA: EMPCELL: EMPCELLPROVIDER: sign/date: PARTSIGNATURE: PARTPRINT:
PARTDATE: IRISSIGNATURE: IRISDATE: CheckBox500: OffCheckBox502:
OffCheckBox501: OffCheckBox504: OffCheckBox503: OffCheckBox507:
OffCheckBox506: OffCheckBox505: OffCheckBox509: OffCheckBox508:
OffCheckBox513: OffCheckBox512: OffCheckBox510: OffCheckBox514:
OffCheckBox519: OffCheckBox518: OffCheckBox517: OffCheckBox516:
OffCheckBox515: OffCheckBox521: OffCheckBox520: OffCheckBox511:
OffEMPDL: MEMSSN: MEMDL: GSR/County: MEMMCID: MEMCELL: poaguard:
guardian checkbox: Offpoa checkbox: OffPTT: Text102: Text101:
Text103: Text104: Text105: Text106: Text107: Text108: Text109:
Text110: Text111: Text112: Text113: Text114: Text115: Text201:
Text202: Text203: Text204: Text205: Text206: Text207: Text208:
Text209: Text210: Text211: Text212: Text213: Text214: Text215:
Text216: Text217: Text218: Text219: Text220:
