Timesheet Documentation for Manual Electronic Visit Verification (EVV)
Direct Care Worker Name
*
Last 4 digits of SSN
*
MCO
*
Please Select
AmeriHealth Caritas PA
PA Health and Wellness
UPMC Community HealthChoices
Participant Name
*
Location of Service
*
Please Select
Allegheny
Armstrong
Beaver
Butler
Washington
Westmoreland
Medicaid ID Number
*
Date of service
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Adjustment Request
*
Please Select
Failed to Clock in/out
Failed to Clock In
Failed to Clock-out
Failed to do Task (POC)
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
End Time
*
Hour Minutes
AM
PM
AM/PM Option
Total Hours
*
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 Signature or Initial
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit 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.
Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit 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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