Keystone First

Time Sheet Documentation for Manual Electronic Visit Verification (EVV) Entries/Edits
Keystone First
Community HealthChoices
Agency name
TIN and Provider ID
Direct care worker name
Last 4 digits of SSN
Participant name
Medicaid ID
Location of service

Location of service:

	Date	Start time	End time	Start time	End time	Total hours worked	Services provided based on individual plans of care

Participant signature
Date

MonthDayYear
Date
Provider signature and agency position
Date

MonthDayYear
Date
I, the undersigned Direct Care Worker, attest that I provided Personal Assistance Services, as described above, to the Participant listed on the time sheet above, and that the hours are true and correct.
Direct Care Worker signature
Date

MonthDayYear
Date
Note: All sections of the time sheet must be completed and signed by the Direct Care Worker, Participant, and Agency Designee. By signing in the designated area(s) above, you are confirming that the hours shown and the services provided were performed by the Direct Care Worker whose name appears on the time sheet. Do not sign blank time and activity sheets.
Coverage by Vista Health Plan, an independent licensee of the Blue Cross and Blue Shield Association.
Should be Empty: