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The document requires detailed information, including the employee's name, employer details, and a comprehensive breakdown of daily work hours from Monday through Sunday. It also includes a section for variable schedules, where the average weekly hours must be indicated. The form concludes with a formal supervisor certification, requiring the supervisor's name, title, contact information, signature, and date to validate the accuracy of the provided information. By requiring authentic verification, the form ensures transparency and compliance with Medicaid service regulations, warning that submission of fraudulent or false documentation may result in the reduction or complete termination of essential medical benefits. 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