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Time Sheet Documentation for Keystone First Manual Electronic Visit Verification (EVV) Entries/Edits

Agency name:

Agency name:

Agency name:

Modern Health Home Care

Direct care worker name:

Roger Moore

Participant name:

Ericka Mcclam

TIN and Provider ID:

84-3038944, 30925588

Last 4 digits of SSN:

2743

Medicaid ID:

Medicaid Id

Location of service:

1373 anchor St

Date

Start time

End time

Total hours worked

Services

Date

Start time

End time

Total hours worked

Services

Participant Signature:

Date:

Date participant

Provider Signature:

Date:

Date provider

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.

Provider Signature:

Date:

Date direct care worker

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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