Provider Time Off Provider Time Off LinkedInThis field is for validation purposes and should be left unchanged.Name(Required) First Last Is this request URGENT?(Required) YES (within 48 hours) NO (3+ days future) Front Desk Confirmation(Required) I have messaged the front desk team(Required)Is this request for an extended leave of absence?(Required) Yes (>14 days out of office) No (1-14 days out of office) Please coordinate directly with your manager and HR for approval. Please reach out by EMAIL for next stepsReason for Request?(Required) Vacation Illness Childcare Personal/Undisclosed Other Block a FULL day or PARTIAL day?(Required) FULL DAY(s) PARTIAL DAY Please block the following date range:[start](Required)[end](Required)Please block the following time range:[start](Required)[end](Required)I am able to extend my availability to make up blocked hours: YES NO If yes, specify(Required) Open up 45’s Expand my hours Other Consent(Required) I understand that the information in this form will be shared with the admirative team(Required)Consent(Required) I understand that I must apply PTO into Insperity, our payroll system, as outlined in my employment contract(Required)Consent(Required) I understand that the primary goal is to retain the patient appointent with the practice and that patient reschedules are prioritized in the following order: SAME TIME (reschedule with alternate provider), SAME DAY (reschedule with same or alternate provider), SAME WEEK (reschedule with the same or alternate provider)(Required)
