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*

I certify that all time in Vesta for this pay period is correct and may be processed as-is.I need to request visit maintenance for this pay period.
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