Time Sheet Documentation for Manual Electronic Visit Verification (EVV) Entries/Edits

Time Sheet Documentation for Manual Electronic Visit Verification (EVV) Entries/Edits
Agency Name*
TIN and Provider ID
XXXXX2072
Participants Name*
Direct Care Worker Name*
Direct Care Worker Last 4N SSN*
Participant Medicaid ID*
Location Of Service*

Location Of Service:*

	Date Of Service	Start Time	End Time	Total Hours Worked	Services Provided Based On Plan Of Care
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Participant Signature*

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Date*

MonthDayYear
Date
Provider Signature And Agency Position
Date

MonthDayYear
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 that the hours are true and correct.
Direct Care Worker Signature*

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Date*

MonthDayYear
Note: All sections of the time sheet must be completed and signed by the Direct Care Worker, Participant, and Agency Designee. By signing in the designated area(s) above, you are confirming that the hours shown and the services provided were performed by the Direct Care Worker
Should be Empty: