Time Sheet Documentation for Manual Electroni Visit Verification (EVV)
Direct Care Worker Name
*
Last 4 digits of SSN
*
Participant Name
*
Medicaid ID Number
*
Location of Service
*
Please Select
Allegheny
Armstrong
Beaver
Butler
Washington
Westmoreland
MCO
*
Please Select
AmeriHealth Caritas PA
PA Health and Wellness
UPMC Community HealthChoices
Date of service
*
/
Month
/
Day
Year
Date
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
End Time
*
Hour Minutes
AM
PM
AM/PM Option
Total Hours
Reason for Adjustment Request
*
Please Select
Failed to Clock in/out
Failed to Clock In
Failed to Clock-out
Reason
*
Please Select
Technical Issue
Client Emergency
Device Battery/Signal Issue
Forgot to Log Due to Care task
Client received the services outside the home
System Glitch or App Not Loading
Client Needed Immediate Assistance Upon Arrival
Explanation for Missed Punch
*
Please Check All the POC Service Completed During the Visit
*
Meal Preparation
Housework/Chore
Managing Finances
Managing Medications
Shopping
Transportation
Hygiene
Dressing Upper
Dressing Lower
Locomotion
Transfer
Toilet Use
Bed Mobility
Eating
Bathing
Laundry
Lotion/Ointment
Stairs
Bladder Incontinence
Bower Incontinence
Grooming Shave
Skin Care
Personal Care T1019
Supervision/Coaching
Participant Initial
*
Date
*
/
Month
/
Day
Year
Date
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
*
Date
*
/
Month
/
Day
Year
Date
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 whose name appears on the time sheet. Do not sign blank time and activity sheets.
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