EVV MANUAL CORRECTION (MISSED VISITS) FORM FOR CLOCK IN AND CLOCK OUT

BRIGHT LIFE HOME CARE, INC

4800 LINGLESTOWN RD SUITE 102

HARRISBURG PA 17112

Tax ID: 84-4957661

Provider ID: 103846242-0001
EVV MANUAL CORRECTION (MISSED VISITS) FORM FOR CLOCK IN AND CLOCK OUT
PARTICIPANT NAME*
Member/Client name
MEDICAID ID
Medicaid ID of member/client
DCW NAME*
Caregiver name
DCW last 4 digits SSN*
Caregiver last 4 social
EVV COORDINATOR NAME
EVV coordinator
Scheduled information and specific reason for manual correction (Missed Visits) for scheduled visits:
Day*
Missed visit Day
Clock in Date *

MonthDayYear
Missed clock in date
Clock out Date*

MonthDayYear
Missed clock out date
Start Time*

Hour Minutes

AM/PM Option
End Time*

Hour Minutes

AM/PM Option
Total Hours Worked*
Total number of hours
Location of Service provided:*

Participant HomeOutside Address:
Duty Codes: [If you have called out through the EVV system, Activities codes are NOT required!]
No duty codes required for missing clock in
Reasons:

New employee, unable to utilize electronic timekeeping systemCalled in to or Out of the EVV system Early or LateForgot to clock in using electronic timekeeping systemForgot to clock out using electronic timekeeping systemWorked after clocking out on electronic timekeeping systemWorked before clocking in on electronic timekeeping systemInterrupted meal break request for paid meal breakMissed meal break request for paid meal breakExperienced non30minute consecutive meal breakElectronic timekeeping system malfunctionProvided Service outside the client’s home addressOther
I certify that Information I provided on and regarding this time sheet is true, accurate and complete. I have provided the services to the consumer according to the care plan. I also, understand that any false statements on this document may be grounds for disqualification of my employment from BRIGHT LIFE HOME CARE, INC.
Employee Signature*

Clear
Sign of Caregiver
Date*

MonthDayYear
Date
Participant Signature*

Clear
Sign of member/client
Date*

MonthDayYear
Date
For Office use only
Approved by Signature

Clear
Title
Print Name
Date

MonthDayYear
Date
Note: FORM MUST BE FULLY COMPLETED & SUBMITTED TO BRIGHT LIFE HOME CARE INC IMMEDIATELY
Should be Empty: