Missed Punch Report with Tasks (Revised 5-1-2025)

📄 MISSED PUNCH FORM – POLICY AND INSTRUCTIONS

📅 UPDATED MAY 1, 2025 — PLEASE READ CAREFULLY

Silver Home Care

EIN 81-2847306

As a Community Health Choices provider, Silver Home Care is required by law to collect time and attendance data through Electronic Visit Verification (EVV) for all Community HealthChoices visits. Therefore:

Employees must clock in and out using one of the following approved EVV methods:

✅ HHAeXchange mobile app, or

✅ HHA Exchange IVR at 888-206-5826 (from the client's landline phone)

This Missed Punch Form is not a substitute for EVV and may only be used in the following situations:

1️⃣ Technical Issues with EVV
⚠️ If the app doesn’t work, you must attempt to use the client’s authorized landline phone to access the IVR. If you do not know your IVR code, call the office and we will provide it.

❌ Do not use your personal phone or the client’s cell phone to call the IVR.

⚠️ If the client has no landline or does not give you permission to use it, or neither method is successful, you must document the reason for both failures on this form.

📞 It is imperative that you call the office immediately to report the issue in real time.

✅ If the issue is reported and verified, it will not count against your EVV compliance rate..

2️⃣ Visits Outside the Client’s Home
✅ You must still clock in and out using the HHAeXchange mobile app from the off-site location.

📝 You must also complete this form to document the details of the off-site visit.

✍️ Client Signature Requirement
Effective May 1st, a client signature is required on all Missed Punch Forms.

✅ The signature must be provided by the authorized individual on file — sometimes that’s the client, other times it’s a representative.

📞 When you call to report the missed punch, we’ll let you know who should sign.

⚠️ If that person is not present, Silver Home Care will follow up to get the signature. This may delay payment of the visit.

🧾 Visit Validation Requirements
To be approved for payment, a visit must include all of the following:

✅ Clock-in and clock-out punches

✅ Task codes entered at the time of service

✅ Required signatures

❌ If any of these elements are missing, the visit will not be approved for payment.

🚨EVV compliance is mandatory.
📞 If you experience a technical issue or are unsure what to do, call the office immediately. We’re here to help — but issues must be reported in real time.
Please enter the reason you were unable to punch in/out using the HHA Exchange App or IVR (phone) system. Select ALL that apply*

App not workingLandline not availableUnable to log in to AppClient refused to allow use of landlineCell phone died or unavailableTechnical issue with landlineOther App ErrorClient does not have a landlinePunched in lateOther IVR ErrorForgot to punch in/outThe visit started and/or ended off-site.
Please enter details:
Your Name*

First NameLast Name
Your Empoyee ID*
Your Email:*
This form is subject to approval.
Client Name (Full) *

First NameLast Name
Client Address (or location of the visit) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's FIRST Name ONLY
Work Date*

MonthDayYear
Date
Timesheet Week Ending*

MonthDayYear
Date
Shift Start*

Hour Minutes

AM/PM Option
Shift End*

Hour Minutes

AM/PM Option
⚠️ Too Early to Submit!
You cannot complete this form until after the shift end time you've entered. The submit button will be disabled until that time.
Current Time

MonthDayYear
Date
Hour MinutesAM/PM Option
calculation

Task List*

	Task
115 - Meal Preparation
116 - Housework/Chores
118 - Managing Medications
119 - Shopping
120 - Transportation
122 - Hygeine
123 - Dressing Upper
124 - Dressing Lower
125 - Locomotion
126 - Transfer
127 - Toilet Use
128 - Bed Mobility
129 - Eating
130 - Bladder Incontinence
131 - Bowel Incontinence
132 - Personal Care
134 - Bathing
135 - Bathing (Shower)

Notes*
Certification: I certify that the information entered is true and correct. I understand that falsification or misrepresentation of this timesheet is Medicaid Fraud and it is a CRIME.*

Employee Acknowledgement
Employee Signature (Must be Legible)*

Clear
*Enter your name her to verify your signature*

First NameLast Name
✍️ Client Signature Requirement

Effective May 1st, a client signature is required on all Missed Punch Forms.

✅ The signature must be provided by the authorized individual on file — sometimes that’s the client, other times it’s a representative.

📞 When you call to report the missed punch, we’ll let you know who should sign.

⚠️ This timesheet is not valid and payable without an authorized signature below. Incomplete timesheets may delay payment of the visit.

All signatures will be verified by the office.
Client/Authorized Signer Name

First NameLast Name
Date

MonthDayYear
Date
Phone
We will call to verify your signature
Client/Authorized Representative Signature

Clear
Manager's Section
Reason for Note

Missing InformationMissing Employee SignatureMissing Client/SignatureNeeds Secondary Signature (ie Authorized Representative)
Please enter details and resolution:
Secondary Signer Name

First NameLast Name
Date

MonthDayYear
Date
Phone
We will call to verify your signature
Secondary Signer Signature

Clear
Verbal Verification
Completed by

ShanellKellyPattiOther
Should be Empty:

Manager's Section