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Chosen Family Home Care Time Sheet Document for Manual Electronic Visit Verification (EVV)

Caregiver's Name: *

Select the client's insurance

Keystone First

UPMC

PA Health and Wellness

Caregiver Last 4 digits of Social Security Number: *

Participant's Medicaid ID Number:

Participant's name (Client receiving care): *

Chosen Family Home Care TIN: *

Keystone First Provider ID:

Address Where CLIENT RECEIVED Home Care Services *

*

Time Log And Duties Completed At Visit

Please fill out all missed shifts for the week in question. Be sure to fill out all items across the row otherwise it is considered incomplete and will not be accepted.

Comments

Please add any additional comments or notes here (if applicable).

Timesheet Attestations & Signature Section

Participant signature:

Clear

Date:

I, the undersigned Direct Care Worker, attest that I provided Personal Assistance Services, as described above, to the Participant listed above, and the hours are true and correct. I acknowledge that any attempt to falsify records is considered Medicaid fraud. Such actions are subject to severe legal consequences, including fines, imprisonment, and exclusions from federal healthcare programs.

Direct Care Worker signature:

Clear

Timesheet 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.

Hospitalizations: Patient hospitalizations/admissions are not billable and must be reported to the office immediately. If a patient is admitted or hospitalized, all Personal Assistance Services are stopped & worker must clock out at that time.

(FOR OFFICE USE ONLY) Company Representative's Name

Company Representative's Title

Signature:

Clear

Date: