Daily EVV Time Correction Form

IMPORTANT: This form can ONLY be used for EVV Corrections. Please do not submit any other documents through the picture upload option.

If you have any questions or issues regarding this form, please contact Caring Companions at [email protected] or call 866-863-5151.

This form only needs to be completed if you need to make corrections to EVV. Attendants using Fixed Visit Verification (FVV) should complete this form to submit EVV while awaiting the arrival of the FVV device, or if it is out of order.

You have two options to electronically submit your EVV Correction Form:

Online Form Option - You can fill out the form, date it, and sign it all online. There is no need to print or email anything.

Picture Upload Option - You can fill out the paper form, take a picture of it with your smart device, and submit it online. You can also use this option to upload a scanned copy of the filled out form.

Choose a form type: *

Instructions

You may submit the EVV Corrections Form to us by taking a picture of the paper form and submitting it via the instructions below.

If you'd like to fill out the form online instead, please choose that option at the beginning of this form.

Steps:

Fill out the paper Daily EVV Time Correction Form.
Click on the Front Page upload button below.
Choose either a picture saved on your device of the form or take a picture of the form.
Repeat the same steps for the Back Page upload button if applicable.
Click submit when you're finished.

Attendant Full Name: *

Phone *

Upload Document

Upload EVV Corrections Form: *

Upload EVV Corrections Form:

Sign and Date

Attendant's Signature: *

Clear

Date Signed: *

Instructions:

The attendant completes all information and both the attendant and consumer signs the bottom of the form.

Please note the following: This form only needs to be completed if you need to make corrections to EVV. Attendant's using Fixed Visit Verification (FVV) should complete this form to submit EVV when awaiting the arrival of the FVV device or if it is out of order.

Consumer's Name: *

Attendant's Name: *

Email *

Shift to be Adjusted:

Date of Shift: *

Shift Start Time: *

Shift End Time: *

Tasks Performed: [tasks completed per service plans - check all that apply] *

Describe in detail your request for the EVV time adjustment.

Reason for needing to make an adjustment to your shift: *

Attendant verification of Clock In/Out: I acknowledge by signing below that I understand I am required to clock in and out of my scheduled shift using the WellSky EVV system. I understand and agree that all missed clock-in/clock-out times are subject to audit by the State of Missouri and that submitting this form with fraudulent information can be considered Medicaid Fraud.

Attendant's Signature *

Clear

Consumer verification of Clock In/out: By signing this form, I hereby certify that I received these documented services on the date and time listed above. I understand that signing this form without having received the services listed can be considered Medicaid fraud.

Consumer's Signature *

Clear