Medical Director Activity Report

Monthly record of medical director hours for facility administration and CMS Payroll-Based Journal (PBJ) reporting.

01Reporting Period & Assignment

Month *

Year *

State *

Community *

Medical Director Name *

Company Employing Medical Director *

02Instructions

Activity reports are to be completed for each month and submitted by the 5th business day of the following month. Medical Director stipends will be paid in the month following service provision. Activity Reports submitted after the 5th business day of the month may not be paid until the following month.

Medical Director activity reports will be used by the facility and Saber Healthcare Group for CMS Payroll Based Journal (PBJ) reporting and internal monitoring of the medical director's activity and hours.

Time spent providing direct patient care — including phone calls, family meetings, on-call duties, etc. for which you are the providing physician — is NOT included in the hours documented below. Only the medical director's hours are to be reported. Do not include hours for Advanced Practice Clinicians, office staff, or ancillary providers.

Time should be reported to the nearest 30-minute increment. Activities that are frequently performed can be reported for the last business day of the month with the total hours provided for the month.

03Activity Log

	Hours Served	Description of Services
1
2
3
4
Total Hours Served	0.0	Auto-summed from rows above · 30-min increments

4 entries

04Certification & Signature

I hereby certify that the information provided above is true and accurate, and that the services were performed by me in the month and year noted. I understand this report supports CMS Payroll-Based Journal (PBJ) submissions.

Medical Director Signature *

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Signed by—

ForMay 2026

Total hours0.0

Submitted—

Email me a copy at

Reports are due by the 5th business day of the following month.