CDS EVV Confirmation/Visit Maintenance Request

CDS Employer EVV Confirmation/Visit Maintenance Request
Submit Date

MonthDayYear
Date
Hour Minutes
Client Name

First NameLast Name
CDS EMPLOYER E-mail
This is where your confirmation of submission will be sent. Please double-check.
Select Pay Period
Please select your Vesta EVV Option
Option 1 must perform visit maintenance through the Vesta EVV system. You will only submit a timesheet for non-EVV services and can do so at this link: https://form.jotform.com/221806496582161
Please select one option
Per state EVV compliance regulations, CDS Employers are required to maintain a Compliance Score of 80% or higher. Manually entered shifts must account for less than 20% or less of the total shifts in each month.

This form will allow you to submit up to 7 edits -- if you need to request more, please submit another form.
How many visit edits do you need to request?
Service 1
Please select the service performed.
Attendant Name 1

First NameLast Name
Date 1

MonthDayYear
Please select the date of the service needing correction.
Time 1

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Reason Code 1
Service 2
Please select the service performed.
Attendant Name 2

First NameLast Name
Date 2

MonthDayYear
Date
Time 2

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Reason Code 2
Service 3
Please select the service performed.
Date 3

MonthDayYear
Date
Attendant Name 3

First NameLast Name
Time 3

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Reason Code 3
Service 4
Please select the service performed.
Attendant Name 4

First NameLast Name
Date 4

MonthDayYear
Date
Time 4

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Reason Code 4
Service 5
Please select the service performed.
Attendant Name 5

First NameLast Name
Date 5

MonthDayYear
Date
Time 5

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Reason Code 5
Service 6
Please select the service performed.
Attendant Name 6

First NameLast Name
Date 6

MonthDayYear
Date
Time 6

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Reason Code 6
Service 7
Please select the service performed.
Attendant Name 7

First NameLast Name
Date 7

MonthDayYear
Date
Time 7

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Reason Code 7
Total Hours
Should be Empty:

CDS Employer EVV Confirmation/Visit Maintenance Request