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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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