HEALTH STAR HOME CARE -EVV EXCEPTION MANUAL FORM

  • EVV EXCEPTION MANUAL FORM

  • Image field 2

  • HEALTH STAR HOME CARE

  • EVV exception manual form is to be used to verify and confirm a visit when an employee fails to perform EVV in and out. The EVV manual form must be kept at minimum and cannot be a primary source of verifying PAS visit.

  • Date*
     - -

  • *Please checkmark ALL Duties Performed by Plan of Care Homemaker tasks are provided only for the participant and not for another household member.

  • Reason for Manual exception*
  • Has any CRITICAL EVENT occurred: ER visit, Hospital, Fall, Abuse, Neglect, etc.?*

  • 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 the hours are true and correct. I also acknowledged that falsifying information about services is a federal offence.

  • Date*
     / /

  • All EVV manual form(s) must be submitted to info@healthstarhomecare.com withing 24-48 hours of the visit. OFFICIAL USE ONLY: In case a participant is unable or unavailable to sign, the agency must verify the visit with WET signatures. Ashley Sullivan-Pernell, Chief Operating Officer Agency Representative Name and Role

  • Verification of EVV manual form is done and documented electronically by agency representative in HHAeXchange. If any information is missing - the agency reserves the right to reject this manual form.

  •  
  • Should be Empty: