Priority - EVV Options Form

ADDRESS: 2 Corporate Dr #202, Central Valley, NY 10917 PHONE: (518) 900-8080 / (845) 781-7376 FAX: (518) 444-0824 EMAIL: info@prioritycareny.com
EVV FORM
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*
EVV Options

select from the available 3 options, Multiple options may be selected if using multiple caregivers.
Consumer’s Landline
- 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 Community Home Health Care to make the necessary changes in the EVV System.
- Consumer's Signature (or Consumer's Representative) Signature
Mobile App
- The Caregiver will receive instructions on how to set up the Mobile App.
- There must be a GPS signal at the consumer’s residence to use the Mobile App.
FOB Device
- The Agency will send a liaison to install the FOB device in the consumer’s residence.
- The Caregiver will follow the fob clock in/out instructions.
Device ID: Seal ID: Device Location:
Should be Empty:

EVV FORM