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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
Feb 3, 2024
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry,204 Hair Care
Jan 31, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry,204 Hair Care
Jan 29, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry,204 Hair Care
Jan 29, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry
Jan 17, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry,204 Hair Care
Jan 16, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry,204 Hair Care
Jan 15, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry
Jan 14, 2024
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry,204 Hair Care
Jan 13, 2024
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry
Jan 12, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry,204 Hair Care
Jan 11, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry
Jan 10, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,137 Lotion/Ointment,138 Laundry
Jan 9, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry
Jan 8, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry,204 Hair Care
Jan 7, 2024
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry
Jan 5, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry,139 Reading/Writing
Jan 4, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder
Jan 2, 2024
17:00:00.000
01:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry
Dec 31, 2023
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry
Dec 30, 2023
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder
Dec 23, 2023
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry
Dec 23, 2023
09:00:00.000
17:00:00.000
Total hours worked
115 Meal Preparation,116 Light Housework,118 Medication Reminder,138 Laundry
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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