EVV Adjustment Request Form

Electronic Visit Verification (EVV) Adjustment Request Form

Growth Ability Services
Date Submitted

YearMonthDay
4 digit year, 2 digit month, 2 digit day
DSP NAME

HOURS TO ADD, DELETE, OR ADJUST:

WHAT HAPPENED? Briefly explain why this adjustment is needed.
DSP PERSONAL STATEMENT
I confirm that, on the dates in question, I was incorrectly clocked in/out due to the reasons selected above. I acknowledge that this request is accurate and understand that any falsification of time records is a violation of company and AHCCCS EVV policy. I request the correction of my recorded hours accordingly.
DSP SIGNATURE:
DATE:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Electronic Visit Verification (EVV) Adjustment Request Form