Provider PTO Request

Name

Center

___________________________________________________________________

For Consecutive Days

Choose Start Date

Choose End Date (Last Day Off)

Reason

___________________________________________________________________

For Individual Days

Choose a Date

Amount of Time

If not a whole day, then how many hours?

If not a whole day, then enter the Start time

If not a whole day, then enter the End time

Reason

Choose a Date (2nd date if needed)

Amount of Time (2nd Date if needed)

If not a whole day, then how many hours? (2nd date if needed)

If not a whole day, then enter the Start time (2nd date if needed)

If not a whole day, then enter the End time (2nd date if needed)

Reason (2nd date if needed)

___________________________________________________________________

Does the time off request include assigned call or weekend coverage? If yes...

I will cover my assigned call/weekend coverage.

I will swap coverage with another provider and will email schedulers the details

AthenaTelehealth Training Information