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
CAREGIVER NAME
Caregiver name
CAREGIVER SSN
Caregiver social
Caregiver Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearCaregiver Date of Birth
EVV COORDINATOR NAME
EVV coordinator
Scheduled information and specific reason for manual correction (Missed Visits) for scheduled visits:
Clock in Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMissed clock in date
Clock out Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMissed clock out date
Day
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:

Outside 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:

Other
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

Sign of Caregiver
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant Signature

Sign of member/client
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approved by Signature
Title
Print Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Note: FORM MUST BE FULLY COMPLETED & SUBMITTED TO BRIGHT LIFE HOME CARE INC IMMEDIATELY
Should be Empty: