EVV Correction Form
Employee Name/Nombre del Empleado:
*
First Name
Last Name
Person Served Name / Nombre del Cliente:
*
First Name
Last Name
Service / Servicio
*
Please Select
PCA
PCA Complex
PCA Extended
Homemaking
IHS- Individualized Home Supports without Training
IHST- Individualized Home Supports withTraining
Respite
ILS- Independent Living Skills
IHSFT- Individualized Home Supports with Family Training
Night Supervison
ICLS - Individual Community Living Supports
SILS- Semi-Independent Living Skills
Email / Correo Electrónico:
*
example@example.com
Date of Error / Fecha de Error:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time In / Entrada
*
Hour Minutes
AM
PM
AM/PM Option
Time Out / Salida
*
Hour Minutes
AM
PM
AM/PM Option
Delete Entry
Delete Entry / Eliminar entrada
Yes
No
Change Services / Cambiar servicios
Yes
No
Reason for Error / Motivo del Error:
*
I have more hours to Submit/Tengo más horas para enviar
Yes
No
Date of Error / Fecha de Error:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time In / Entrada
Hour Minutes
AM
PM
AM/PM Option
Time Out / Salida
Hour Minutes
AM
PM
AM/PM Option
Delete Entry
Delete Entry / Eliminar entrada
Yes
No
Change Services / Cambiar servicios
Yes
No
Reason for Error / Motivo del Error:
I acknowledge by signing below, I understand I am required to clock in and out of my shift using the EVV system. I understand and agree that all missed punch in/punch out are subject to an audit by the State of Minnesota. It is a FEDERAL CRIME to provide materially false information on service billings for Medical Assistance or services provided under a federally approved waiver plan as authorized under MN Statues, sections245B.013, 245B.0915, 256B.092 and 256B.49.My signature verifies the time and services entered above are accurate and that the services were performed as specified in the Care Plan of the Person Served.
*
Accept
Signature
*
Submit
Should be Empty: