Team Member Change Form

Team Member Change Form

Team Member ID number*

(Their Employee ID in Paylocity)

Last Name*

First Name*

Credentialed or Non-Credentialed*

Select

Current Position*

Location/Dept*

Select

What is changing?*

Employment Status

Pay Rate

Position

Work Location

Leader

Something else

Effective Date of the Change*

Employment Status Change*

Termination

FT to PT (<30 hours/week)

PT to FT (>30 hours/week)

FT/PT to PRN

Termination Reason*

Select or enter value

Do we need to retain any software access after termination?*

For example: access to email inbox post-termination for 6 months, inbox forwarded to another user, etc.

Yes

Microsoft Account

Please select the appropriate action for the Employee's Microsoft 365 Account.

Delete M365 Account: Remove the account completely, we do not need access to files, emails, etc.
Convert to Shared Mailbox: Retains contents of the mailbox for access, post-termination.

Select or enter value

If yes to the need to retain access, please provide context/details:

Does the employee have OpenPath Access that needs to be deactivated?*

Yes

Does the employee have company assets that need to be returned?

Which assets need to be collected?

Select all that apply. Recovering company assets at the time of separation is the responsibility of the manager, please work with the PRC team if you need any guidance.

Laptop/PC

Computer Monitors

Docking Station

Keyboard

Mouse

Webcam

Employee ID/Badge

Scrubs

Credit Card

New Pay Rate*

New Position*

Select or enter value

New Work Location*

Bardstown

Campbellsville

CMM

Complete Care

Crestview Hills/Carrollton

Elizabethtown

Evansville East

Evansville West

Jasper

Lexington

London

Mt Carmel

New Albany

Occupational Medicine

Owensboro

Physical Therapy

Pikeville

St Matthews

Vincennes

CBO - Billing

CBO - Contracts & Credentialing

CBO - Denial Management

CBO - New Patient Scheduling

CBO - Patient Support

CBO - Prior Authorization

Corporate - Executive

Corporate - Finance

Corporate - HR

Corporate - Marketing

New Leader*

Something Else*

Additional Information

Supporting Documentation (if applicable)

Drag and drop files here or

Send me a copy of my responses

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