• Electronic Visit Verification (EVV) Exception and Issue Form

    This form is only for true EVV exceptions, app/software issues, or approved manual visit entry requests. It is not a replacement for real-time EVV clock-in and clock-out for non-live-in caregivers. Non-live-in caregivers must use the approved EVV method to capture real-time clock-in, real-time clock-out, and the correct GPS service location. Repeated EVV issues may cause visits to be out of compliance and require office follow-up or additional training. Live-in caregivers may use this form for approved manual visit documentation. A separate form is required for each date of service unless approved by the office.
  • Actual Date In*
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  • Actual Date Out*
     - -
  • Service Type (CFSS or PCA)*
  • Date(s) of Visit*
     - -
  • Approved Activities*

  • Worker

    I declare under penalty of perjury that the hours worked and descriptions of services provided on this form are true and correct to the best of my knowledge. I understand that this information may be subject to review or investigation and that knowingly providing false or inaccurate information may result in denial of payment, disciplinary action, and/or referral to the appropriate authorities.

    Client/Responsible Party Verification

    Please review for accuracy before signing. By signing, you verify that the dates, times, and services listed on this form are accurate to the best of your knowledge and that the services were provided by the worker listed in accordance with the client's service plan.

     

  • Attestation

  • By signing below, I verify that the information above is true and accurate.
  • Should be Empty: