EVV FORM
Consumer's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EVV LANDLINE:
Please note: Our agency offers other options for EVV. For any questions, please reach out to your Case Manager.
I certify that my landline number is:
Phone Number
*
I will make sure the landline is available for use by the caregiver to call in when the shift begins and to call out when the shift ends.
If my landline number changes, I will immediately notify Priority Home Care to make the necessary changes in the EVV System.
Consumer's Signature (or designated representative)
*
Consumer (Patient) Name:
Physical Address:
Address where consumer is receiving Home Care Service (if same as physical address, write "Same"):
Consumer's Landline:
Consumer's Other Contact Info (ex. cell phone)
Emergency Contact:
Name:
Relationship:
Address:
Phone:
Lives with Consumer: Yes/No
Please Select
Yes
No
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